Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy (97012) provided on  
August 6, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the mechanical traction therapy (97012) provided on August 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798, and 87641 
billed for date of service December 20, 2021. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87653, 87798, and 87641. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87150, 87481, 
87653, 87798, and 87641 is bundled into payment for code 87801. 
 
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 codes 
87150, 87481, 87653, 87798, and 87641 are column II codes to column I code 87801. 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 procedure codes 87150, 87481, 
87653, 87798, and 87641 billed for date of service December 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
September 10, 2021, to September 23, 2021, at the billed rate code. 
 
You asked the Plan to pay for SNF care. You say that these services were billed correctly and are supported in 
the records provided. The Plan denied your request. The Plan says the records do not support the rate code used 
on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report SNF services with the appropriate HIPPS code. The rules also say that as the last day of 
the look-back period, the Assessment Reference Date (ARD) serves as the reference point for determining the 
care and services captured on the Minimum Data Set (MDS) assessment. Anything that happens after the ARD 
will not be captured on that MDS. 
 
We looked at the file and Medicare rules. The record shows that the MDS assessment for the relevant section(s) 
was signed and dated on September 23, 2021, which is after the ARD date of September 16, 2021. 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 pay for skilled nursing facility (SNF) services provided from September 
10, 2021, to September 23, 2021, at the billed rate code.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 36415, 83540, 84466, 
85025 and 85045. We decided that the Plan does not have to pay for the services described by procedure 
code(s) 83550.  
 
You asked the Plan to pay for the services provided on July 6, 2022. You say that these services are supported 
in the medical record. The Plan says that the payment for code 83550 is included in the payment for code 
84466. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 36415, 83540, 84466, 
85025 and 85045.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 36415, 83540, 84466, 85025 
and 85045.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
83550. 
 
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 83550 
is a column II code to column I code 84466 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met for code 83550 Therefore, 
we decided that the Plan does not have to pay for the services described by procedure code(s) 83550. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 14, 2022, to 
April 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you attached proof the NOA was 
sent, and the claim should be reviewed for payment. The Plan denied your request. The Plan says the claim has 
not been billed with the correct admission date. 
  The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 14, 2022, to April 
12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service October 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 6, 2022, to 
March 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 6, 2022, to March 
23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of procedure code 76642 and 77065 
provided to the enrollee on May 7, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no indication that an additional mammogram or breast ultrasound was performed or 
ordered on this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 The medical records have two reports with the same exact information contained in them. Tere is no evidence 
that additional services were rendered. Based on this information, we decided that Medicare rules for coverage 
of the services have not been met. Therefore, we decided that the Plan does not have to pay for additional units 
of procedure code 76642 and 77065 provided to the enrollee on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning (99497-25) provided on June 1, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the submitted medical records do not include the documentation of a discussion between the 
provider and the patient, along with family member(s), or surrogate(s), regarding eventual end-of-life decisions 
and preferences. 
 
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, the CPT Code Manual definition of code 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health professional; first 30 minutes, face- to-face with the patient, family member(s) and/or surrogate). 
 
We asked our coder 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 service. Our reviewer found CPT code 99497- 25 (1 unit) 
remains not supported. The submitted medical records did not include the documentation of a discussion 
between the provider and the patient, along with family member(s), or surrogate(s), regarding eventual end-of-
life decisions and preferences; therefore, the billed service cannot be verified. The review has determined that 
the documentation did not support procedure code 99497. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for advance care planning (99497-25) provided on June 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of bone marrow aspirate is 
considered experimental in cases of spinal surgery when used as a bone graft extender. More research is needed 
to support its safe and efficacy. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99243 billed for date of service April 13, 
2022. 
 
You asked the Plan to pay for procedure code 99243. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99243 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99243 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99243 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99243 billed for date of service April 13, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 92928-RC and 93459-26-
59. We decided that the Plan does not have to pay for the services described by procedure code 99153.  
 
You asked the Plan to pay for the medical services provided on June 24, 2022, billed with codes 92928-RC, 
93459-26-59, and 99153. You say that the medical records support that payment should be made for the denied 
services. The Plan says that the code 99153 cannot be paid in a facility setting. No decision was rendered on 
the other denied codes. 
 
We decided that the Plan has to pay for the services described by procedure codes 92928-RC and 93459-
26-59.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan did not provide any explanation as to why these denied codes were not reviewed at the appeal 
level. As the Plan forfeited its opportunity to provide a denial rationale for these services, we find that the 
denial of payment is not supported. Therefore, we decided that the Plan has to pay for the services described by 
procedure codes 92928-RC and 93459-26-59.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 99153. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the services described by procedure code 99153. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0482) provided on August 29, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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, the CPT Code Manual definition of code G0482 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
15-21 drug classes were tested on the date of service in question. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services (G0482) provided on August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tuberculosis screening (86480) provided on 
 
You asked the Plan to pay for the tuberculosis screening. You say that this test was medically necessary and is 
supported as billed. The Plan denied your request. The Plan says this test was provided for screening purposes 
but is not covered by Medicare for screening purposes. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the tuberculosis screening, was requested solely for screening purposes. The 
diagnosis reported on this claim, Z11.1, supports that this test was only a screening. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
tuberculosis screening (86480) provided on
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services (A0434, A0425) provided on July 12, 
2022. 
 
You asked the Plan to pay for transportation services. You say that the enrollee was not inpatient status on the 
date in question. The Plan denied your request. The Plan says the payment for these services is bundled into the 
facility payment where the enrollee was registered inpatient on the date in question. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a facility, it may 
be necessary to transport the beneficiary to another hospital or site temporarily for specialized care while the 
beneficiary maintains inpatient status with the original provider. This movement of the patient is considered 
patient transportation and is covered in the payment made to the facility. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of transportation services have not been met. Specifically, the record shows that the enrollee 
maintained inpatient status at one facility from July 11, 2022, to July 15, 2022. This means that the services at 
issue are considered patient transportation and are paid to the facility. Therefore, we decided that the Plan does 
not have to pay for transportation services (A0434, A0425) provided on July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foot insert (L3010). 
 
You asked the Plan to pre-approve the foot insert (L3010). You say that the purpose of the custom molded 
ankle-foot orthoses is to relieve pain, accommodate present deformity, and prevent further deformity. The Plan 
denied your request. The Plan says based on the information received on appeal, the requested service is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that inserts and other shoe modifications (such as 
L3010) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically 
necessary for the proper functioning of the brace. 
  
We looked at the file and Medicare rules. Orthotic shoes were not requested as part of this brace meaning 
inserts are not covered under the circumstances. Based on this information, we decided that Medicare rules for 
coverage of the foot insert have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a foot insert (L3010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional radiation therapy (77014 x5 and 77386). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says this amount of radiation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no evidence basis to use 40 fractions at 1.8 Gy per fraction. The appeal letter states that 
1.8 Gy fractions were chosen to spare uninvolved lung, which does not make sense and not supported by any 
evidence or guidelines. IMRT is plausibly used to spare lung but not non-standard fraction sizes. Our physician 
reviewer found the additional five fractions beyond 35 fractions are not necessary. Treating beyond 35 
fractions is not consistent with National Comprehensive Cancer Network (NCCN) guidelines or American 
Society of Clinical Oncology (ASCO) Guidelines and therefore, not in accordance with accepted standards of 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional radiation therapy (77014 x5 and 77386).