Persius/hicric huggingface dataset:
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 May 8, 2022. 
 
You asked the Plan to pay for procedure code 99100. 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 May 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you should not be 
driving yourself. The Plan denied your request. The Plan says the request exceeds the limit listed by your Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. We looked at your request, the records in the case file, and the rules. Based on this information, we 
decided that the Plans rules for coverage of routine transportation have not been met. The Plan stated you 
received 23 out of 24 available rides between January 20, 2022, and August 29, 2022. The 25th trip and beyond 
is not a covered benefit. Your 2022 EOC says up to 24 one-way trips per year; therefore, this request exceeds your Plan benefits. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing (83789) provided on March 11, 
2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing (83789) provided on March 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan for the enrollee. 
 
You asked the Plan to pre-approve a CT scan. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that they did not receive a detailed history that shows this study is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve a CT scan. Our reviewer says that a CT 
scan is not medically reasonable and necessary. The enrollee suffered a fall in June 2022. The record indicates 
that an MRI at the time demonstrated changes at the time at C4 consistent with degenerative disc disease and 
possible intravertebral hemangioma although a compression fracture could not be ruled out. At a September 
visit, the record indicates that the enrollee had a normal neurologic examination and a diagnosis of spondylosis 
and abnormal gait. The record does not provide a clinical rationale for the requested study or how management 
would be altered by the results of the requested study. Our physician reviewer found that the enrollee's 
condition does not meet criteria for a CT scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the leg stent surgery. 
 
You asked the Plan to pre-approve the surgery. You say that the services are necessary. The Plan denied your 
request. The Plan says the tests the enrollee has had have not shown a significant blockage in the leg arteries. 
 
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 surgery. Our physician reviewer 
found the documentation does not meet coverage criteria and does not support the medical necessity of the 
procedure in question. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the leg stent surgery.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you are appealing the denial of continued 
SNF care. The Plan denied your request. The Plan says you do not meet SNF Medicare Criteria found in the 
Medicare Benefit Policy Manual under Chapter 8, Section 30 as you have not demonstrated consistent benefit 
from skilled therapy services and there is no evidence of rehabilitation potential to be achieved within a 
reasonable timeframe due to lack of participation.  
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 continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
Our reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (20704) provided on January 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the add-on code was 
not billed with an appropriate primary procedure code. 
 
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 20704 
is an add-on code and has not been billed with an appropriate primary procedure code. 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 services (20704) provided on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA molecular signature test provided to the 
enrollee on March 2, 2022.  
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the denial was appropriate given the clinical scenario. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the PrismRA molecular signature test was provided to the enrollee on March 2, 2022, to evaluate her 
sensitivity to medications used to treat rheumatoid arthritis. The patient reported symptom severity as a 2 out of 
a scale of 1 to 10, 10 being worst. Also, there was no mention of which drug was being considered for use or 
which one was being used currently as required by the criteria which states, "The provider performing the 
service must have a record of what drug(s) is/are being considered and for what indication(s) to ensure the test 
performed is reasonable and necessary." Therefore, the enrollee does not meet criteria for this testing. 
 
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 pay for the PrismRA molecular signature test provided to the enrollee on March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99203) provided on September 25, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you disagree with the denial and would like to 
request reconsideration of payment on this claim. The Plan denied your request. The Plan says enrollees must 
get care from network providers. 
 
 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99203) provided on September 25, 
2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93010) provided on March 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation. Wherever such a combination exists, there is a use additional code note at the 
etiology code, and a code first note at the manifestation code.  
 
We looked at the file and Medicare rules. The record shows that the claim was billed with diagnosis code 
R65.10. This code has a code first note, which means it is a manifestation code and must be sequenced after an 
etiology code Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pay for the services (93010) provided 
on March 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
March 1, 2022, to March 2, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not have to 
pay the emergency room copayment since you were admitted to the hospital. The Plan denied your request. The 
Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for In-Network Emergency Services. Your contract also says that you do not pay the emergency 
room visit cost share if you are admitted to the same hospital that the emergency visit took place in. You were 
transferred for admission to a different hospital; therefore, the emergency care copayment still applies to this 
claim. 
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency Care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an emergency room visit provided on March 1, 
2022 to March 2, 2022.
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 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. 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 medically necessary. Our physician reviewer found the enrollee was admitted to a 
long term acute care hospital (LTACH) after a prolonged hospital stay with congestive heart failure and 
multisystem organ failure on August 31, 2022. He is medically improving and does not need physician supervision three times a week in an IRF. No acute rehabilitation nursing needs are identified or documented. 
The records do not support that he will tolerate the intensity of a rehab program in the IRF. The IRF services 
are 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 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services 
for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that the member's medical needs can be met at lower level of care. 
 
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 found to be medically reasonable and necessary for this enrollee. Hip fracture is an IRF 
compliant diagnosis. Clinical documentation shows that patient will continue to require close medical 
monitoring on an inpatient basis. Evaluating therapists (physical and occupational therapy) both specifically 
recommend intense (3hrs of therapy per day) therapy thus IRF criteria have been met and is medically 
necessary. Our physician reviewer found that the enrollee's condition meets Medicare criteria for IRF 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.  
 
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 to the enrollee from 
March 17, 2021, to April 7, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the Plan did 
not receive the initial RAP claim within 5 calendar days. Therefore, we decided that the Plan does not have to 
pay for the home health services provided to the enrollee from March 17, 2021, to April 7, 2021.
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 LTACH care is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for LTACH 
care have not been met. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute-care services that can safely be administered at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the spine x-ray provided on February 28, 
2022. 
 
You asked the Plan to waive the copayment for the spine x-ray. You say that your primary doctor sent you for 
x-rays and you don't remember having to pay for x-rays before. You say that you object to paying $50. The 
Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment for x-rays in a primary care physician or specialist office and a $50 copayment for x-rays in all 
other locations.  
  You have been asked to pay a $50 copayment for the spine x-ray. The spine x-ray falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the spine x-ray provided on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete denture - maxillary (CPT code D5110). 
 
You asked the Plan to pre-approve the complete denture - maxillary. You say that the complete denture - 
maxillary is necessary. The Plan denied your request. The Plan says the request exceeds the limit listed by your 
Plan. 
 
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. Review of the file shows that 
you had this service done on October 7, 2021. Your 2022 EOC says that complete upper denture (D5110) - one 
(1) procedure every five (5) plan years. Therefore, you request exceeds your benefit. Therefore, we decided that 
the Plan does not have to pre-approve the complete denture - maxillary (CPT code D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gynecological services provided on February 11, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the gynecological services provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services.  
 
Furthermore, we have confirmed that codes G0444 and G0442 are column II codes to column I code 99202. 
This claim has not been billed with an appropriate modifier to bypass the edit. 
 
Additionally, code 99401 has a status code of N under the MPFSDB and is a non-covered service per 
Medicare guidelines. 
 
Therefore, we decided that the Plan does not have to pay for the gynecological services provided on February 
11, 2022, by an out-of-network (OON) provider.