Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the critical care services. We decided that the Plan does not have to pay 
for additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes (99292).  
 
You asked the Plan to pay for the critical care services. You say that critical care has been denied as bundled on 
this claim. Per CMS and AMA this is a payable service and not bundled. The Plan says that the payment for 
this service is included in the fee for the procedure. 
 
We decided that the Plan has to pay for evaluation and management of the critically ill or critically 
injured patient, first 30-74 minutes (99291).  
 
We also decided that the Plan does not have to pay for additional block(s) of time, of up to 30 minutes 
each beyond the first 74 minutes (99292). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the critical care services. Our reviewer says 
that the records partially support the billed services. Our physician reviewer found the records do not support 
the critical care services to be bundled. The total critical care time documented was 76 minutes therefore, the 
use of critical care CPT code 99291 is supported by the medical record and the use of critical care code 99292 
is not supported by the medical record.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the critical care services have been met. Therefore, we decided that the Plan has 
to pay for evaluation and management of the critically ill or critically injured patient, first 30-74 minutes 
(99291) and does not have to pay for additional block(s) of time, of up to 30 minutes each beyond the first 74 
minutes (99292). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), nail debridement (11721) and FQHC 
visit (G0467) provided by an out-of-network provider on October 7, 2021. 
 
You asked the Plan to pay for the office visit (99213), nail debridement (11721) and FQHC visit (G0467). You 
say that you were told the doctors are in-network. The Plan denied your request. The Plan says the office visit 
and nail debridement were denied as out-of-network services were not authorized. The Plan also says an invalid 
claim type was billed for CPT code G0467. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for the office visit (99213) and 
nail debridement (11721). In addition, CPT code G0467 has not been billed on the appropriate claim. 
Therefore, we decided that the Plan does not have to pay for the office visit (99213), nail debridement (11721) 
and FQHC visit (G0467) provided by an out-of-network provider on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office emergency care rendered on July 27, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99058 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99058 (service[s] provided on an emergency 
basis in the office, which disrupts other scheduled office services, in addition to basic service) has a status 
indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for 
the office emergency care rendered on July 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on May 17, 2021, 
billed with code 88305. 
 
You asked the Plan to pay for the surgical pathology services. You say that this testing should be paid in full. 
The Plan denied your request. The Plan says only the professional component of 88305 can be paid as the 
enrollee was a hospital outpatient. 
 
The Plan must follow Medicare rules. Medicare rules say that payment cannot be made for the TC of physician 
pathology services for testing rendered to hospital patients. 
 
In this case, the provider billed the global procedure for 88305, which includes the professional component and 
TC. As this was provided for a hospital patient, the TC is included in payment to the facility and cannot be paid to the physician/lab. Therefore, we decided that the Plan does not have to pay for the surgical pathology 
services provided on May 17, 2021, billed with code 88305.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee requires ongoing acute care services and these have not been denied. The 
enrollee does not require services that she is not currently receiving but that would be available at the LTACH 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80053, 80061, 82306, 82550, 83036, 83090, 
84439, 84443, 84480, 84481, 85025, 86141, G0483) provided March 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80053, 80061, 82306, 82550, 83036, 83090, 84439, 84443, 84480, 84481, 85025, 
86141, and G0483 are not supported in the medical record. Specifically, the place of service listed on the claim 
form (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (80053, 80061, 82306, 82550, 83036, 83090, 
84439, 84443, 84480, 84481, 85025, 86141, G0483) provided March 11, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdomen (76705) provided on 
September 17, 2021. 
 You asked the Plan to pay for the ultrasound of the abdomen. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has 
not been billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the ultrasound of the abdomen (76705) provided on September 
17, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ER visit, and self-administered drugs provided from 
August 6, 2020, through August 7, 2020. 
 
You asked the Plan to pay for the ER visit and self-administered drugs. You say that you included a copy of 
your discharge from the hospital and your secondary insurance. You say that you hope the outstanding balance 
of $166 will be covered. The Plan denied your request. The Plan says the copayment applied correctly, and 
self-administered drugs are not covered by Part B. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The rules say that Medicare Part B generally does not pay for self-
administered drugs.  
 
You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. You have also been asked to pay $46 for the self-administered drugs. The self-administered 
drugs requested here are not among the types which are covered by Medicare Part B. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan 
does not have to pay for the ER visit, and self-administered drugs provided from August 6, 2020, through 
August 7, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) infectious agent 
detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 
(Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique 
(87426) provided June 19, 2021. 
 
You asked the Plan to pay for the clinic visit. You say that the provider knew it was not able to bill Medicare 
from the moment they got all your information and acted in a malicious way to generate income. The Plan denied your request. The Plan says If you go to a provider who is not eligible to participate in Medicare, you 
will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit 
(G0463) infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome 
coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex 
amplified probe technique (87426) provided June 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve an incisional biopsy of oral tissue. You say that the service at issue is 
medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
incisional biopsy of oral tissue (D7286).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next Blood Glucose test strips. 
 
You asked the Plan to pre-approve Contour test strips. You say that this specific brand of test strip is medically 
necessary over the Plan's preferred brand. The Plan denied your request. The Plan says an exception is not 
warranted for the non-preferred test strips. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Contour Next Blood Glucose test strips 
have been met. Specifically, no medical records were provided in this case to indicate the medical necessity of 
the requested test strips over the Plans preferred brand. Therefore, we decided that the Plan does not have to 
pre-approve Contour Next Blood Glucose test strips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to go home because you are unable 
to care for yourself and staying in the hospital without the correct therapy would cause muscle deterioration. 
The Plan denied your request. The Plan says your request does not meet Medicare guidelines because you are 
receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do have 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. You do not meet all of the criteria for coverage of SNF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing provided to the enrollee on August 6, 2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found review indicates that the enrollee underwent genetic testing for the evaluation of myelodysplastic 
syndrome. The myelodysplastic syndromes (MDS) are associated with a diverse set of acquired somatic genetic 
abnormalities. Bone marrow karyotyping provides important diagnostic and prognostic information and should 
be attempted in all patients who are suspected of having MDS. The review has determined that the genetic 
testing in this case was medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have been met. Therefore, we decided that the Plan has to pay for 
genetic testing provided to the enrollee on August 6, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's medical and therapy needs could be met in a skilled nursing unit. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the documentation does not support that at this time the enrollee is reasonably 
expected to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90791, 90834) provided on August 
3 to September 28, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the Plan should pay for the services you 
received since the cost of the services at issue is surely less than if your condition had worsened and inpatient 
treatment became necessary. The Plan denied your request. The Plan says rules for payment have not been met 
because the provider at issue is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90791, 90834) 
provided on August 3 to September 28, 2021.