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

 
We decided that the Plan does not have to pay for laboratory services (procedure codes 87899, 87900) provided 
to the enrollee on March 3, 2022. 
 
You asked the Plan to pay for the services. You say that these services were medically necessary and should be 
paid. The Plan denied your request. The Plan says the records do not support the 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
Current Procedural Terminology (CPT) 87899 - Streptococcus, Group A not otherwise specified 
 
Current Procedural Terminology (CPT) 87900 - Infectious agent drug susceptibility phenotype prediction using 
regularly updated genotypic bioinformatics 
 
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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that in terms of CPT 87899, the 
laboratory report does not include documentation of infectious agent by immunoassay with direct optical, 
meaning visual, observation.  This code is used for organisms not specifically identified by another analysis 
code. In terms of CPT 87900, the laboratory report does not include documentation of infectious agent drug 
susceptibility phenotype prediction using updated genotypic bioinformatics.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure codes 87899, 87900) provided to the enrollee on March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT) (77523). 
 
You asked the Plan to pre-approve PBRT. You say that per Medicare guidelines, proton therapy is a covered 
benefit. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient prospective, long-term clinical data available to determine whether or not 
proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external beam radiation 
therapy, IMRT, or brachytherapy with regards to safety and efficacy. Recent data shows no significant 
differences in late (years one, two, and three) patient-reported toxicity outcomes between proton beam therapy 
and IMRT. The most recent AUA and NCCN guidelines state that PBT offers no clinical advantage over other 
forms of definitive treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Radiation Therapy (PBRT) (77523).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 8, 2022, to April 25, 2022. 
 
You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 pay for 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 that at the time of discharge from the hospital, the enrollee had stabilized 
medically.  The enrollee did not require any skilled nursing or rehab services on a daily basis at an inpatient 
level of care. She was not expected to make measurable gains within a reasonable and predictable period of 
time or require skilled therapy to prevent deterioration with mobility or self-care tasks. The enrollee did not 
require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member 
did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from 
the hospital. The enrollee did not have any parental medications, complex wound care or nutrition given via a 
feeding tube. She was medically stable without any acute exacerbations of chronic medical problems.  Her 
physical function was at or near her baseline and she could have received further services at a lower level of 
care. Admission to the nursing facility at a skilled level of care for inpatient skilled services was not medically 
necessary from 4/8/22 through 4/25/22. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from April 8, 2022, to April 25, 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 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 enrollee was admitted for pneumonia, sepsis, and respiratory failure. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that the enrollee 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 29, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 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 code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 code 70450 billed for date of service July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), electronic connection 
(E2311), and a harness (E2313). 
 
You asked the Plan to pre-approve an expandable controller, electronic connection, and a harness. You say that 
the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
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 an expandable controller, electronic 
connection, and a harness. Our reviewer says that [state physician reviewer's conclusion, e.g. "the service is not 
medically necessary." or "you need this medical item."] Our physician reviewer found the items are not 
medically necessary. The requested items exceed your medical needs and does not meet Medicare medical 
necessity criteria, as Medicare does not pay for any items or services that are not reasonable and necessary for 
the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, electronic connection, and a harness have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), 
electronic connection (E2311), and a harness (E2313).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay from March 
10, 2022, to April 15, 2022. 
 
You asked the Plan to waive the copayment for a skilled nursing facility stay. You say that you needed extra 
time to heal before going home. You feel this was necessary and therefore, you should not have to pay this 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $194.50 
copayment each day for days 21 through 100 for skilled nursing facility (SNF) services.  
 
You have been asked to pay $194.50 copayment each day for days 21 through 100 for a skilled nursing facility 
stay. This item/service falls within the skilled nursing facility (SNF) services 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 a skilled nursing facility stay 
from March 10, 2022, to April 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this device is medically necessary. 
The Plan denied your request. The Plan says there is not enough evidence to show that this device would 
improve health outcomes. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the Food and Drug Administration (FDA) 
in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary 
artery pressure in the management of patients with congestive heart failure. The clinical study on which FDA 
approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was 
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 13, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 procedure code 76705 billed for date of service July 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service July 11, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70553. 
 
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 70544 
is a column II code to column I code 70553. 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 code 70544 billed for date of service July 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the insulin administered via an external 
pump provided between January 1, 2022, and September 16, 2022. 
 
You asked the Plan to reduce the cost sharing for the insulin administered via pump. You say that you were 
told that your insulin would be covered under Part D and would have a $25 copayment. You say that the 
representatives were aware that you used a pump and that you only enrolled in this Plan due to the cost of your 
insulin that you were quoted. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the insulin administered via pump. The pump itself is 
considered durable medical equipment, and the insulin used with it is considered a related supply. 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 reduce the cost sharing for the insulin administered via an external pump provided between 
January 1, 2022, and September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 87150-XU (10 units) billed for date of service June 29, 
2022. 
 
You asked the Plan to pay for code 87150-XU (10 units). You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says code 87150-XU (10 units) is not supported in 
the medical record. The documentation does not contain results to support organism culture and typing by 
nucleic acid probe. 
 
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 87150-XU (10 units) is  Culture, typing; identification by 
nucleic acid (DNA or RNA), probe, amplified probe technique, per culture or isolate, each organism probed. 
 
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 code 87150-XU (10 units). Our reviewer says that code 87150-XU (10 units) is not supported in the medical record. Our reviewer found the results of this testing were 
not included in the records provided, so this code is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87150-XU (10 units) have not been met. Therefore, we decided that the 
Plan does not have to pay for code 87150-XU (10 units) billed for date of service June 29, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the respiratory panel provided on December 17, 2021. 
 
You asked the Plan to pay for the respiratory panel. You say that this service was billed appropriately and 
should be covered. The Plan denied your request. The Plan says that it initially denied this claim because the 
diagnosis code billed was not appropriate.  On its second review, the Plan denied the claim, stating that for this 
panel to be covered, it must be ordered either in a healthcare setting that is equipped to care for and routinely 
does care for critically ill patients, or it must be ordered by an infectious disease specialist (unless one is not 
available.) 
 
The Plan follows Medicare rules. Medicare rules say that Respiratory Viral panels are coverable when certain 
diagnoses are billed in addition to certain signs or symptoms being present. 
 
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 respiratory panel. Our reviewer says that 
the billed diagnosis supports payment for this service. Our physician reviewer found Per icd coding guidelines 
the use of diagnosis code Z20.822 is allowable and payable. The coding is correct and procedure code 0241U is 
supported by the medical records. It should be noted that the Plan has stated that "for this panel to be covered, it 
must be ordered either in a healthcare setting that is equipped to care for and routinely does care for critically 
ill patients, or it must be ordered by an infectious disease specialist (unless one is not available.).  The Plan has 
provided absolutely support for this portion of its denial.  It has provided no evidence that this service was not 
performed in such a setting or ordered by an appropriate provider.  The Plan has not proven anything about the 
availability of an infectious disease specialist.  
 
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 respiratory panel have been met. Therefore, we decided that the Plan has to 
pay for the respiratory panel provided on December 17, 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.