Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for simple repair of superficial wounds (12011) and moderate 
sedation services (99153) provided on August 30, 2021. 
 
You asked the Plan to pay for 12011 and 99153. You say that these services were correctly identified and were 
billed correctly as separate procedures. The Plan denied your request. The Plan says a National Correct Coding 
Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 25605 and 12011. This PTP edit has a 
modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. This service was not billed as required by Medicare coding 
regulations. In addition, CPT code 99153 was established as a technical component-only code, meaning that 
there is no work component relative value unite (RVU) associated with that service. The 2020 Calendar Year 
(CY) final rule established CPT codes 99151, 99152 and 99155-99157 as representative of the work 
component for moderate sedation services. Based on this information, the Medicare rule for payment of this 
claim has not been met. If the provider determines that a billing error occurred during the initial submission of 
the denied claim, the plan will accept a corrected claim to consider services for payment. 
 
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 12011 is a column II code to column I code 25605. 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.  
 
In tis case, CPT code 99153 has a Professional Component (PC)/Technical Component (TC) indicator of 3 - 
this indicator identifies stand- alone codes that describe the technical component (i.e., staff and equipment 
costs) of selected diagnostic tests for which there is an associated code that describes the professional 
component of the diagnostic test only. An example of a technical component only code is CPT code 93005-
Electrocardiogram; Tracing Only, without interpretation and report. It also identifies codes that are covered 
only as diagnostic tests and therefore do not have a related professional code. Modifiers 26 and TC cannot be 
used with these codes. The total RVUs for technical component only codes include values for practice expense 
and malpractice expense only. 
 
We find that CPT code 99153 is not supported in the record. Specifically, 99153 always describes the technical 
component of this service, but a code describing the professional component is required for payment in this 
case. Therefore, we decided that the Plan does not have to pay for simple repair of superficial wounds (12011) 
and moderate sedation services (99153) provided on August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 23, 2020. 
 
You asked the Plan to pay for the laboratory 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. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on November 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Udenyca. 
 You asked the Plan to pre-approve Udenyca. You say that this is medically necessary. The Plan denied your 
request. The Plan says the denial of authorization for this drug is correct, because the enrollee is enrolled in a 
clinical trial so routine costs of the trial would be covered by Original Medicare instead of the Plan. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Udenyca as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve use of Udenyca.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery services. 
 
You asked the Plan to pre-approve spine surgery. You say that this is medically necessary. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not 
meet criteria for this surgery. 
 
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 spine surgery. 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 imaging study showing severe spinal stenosis or spinal instability. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services (procedure code 72131) provided 
to the enrollee on November 11, 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 additional documentation supporting an additional study which was billed and 
remains denied. 
 
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 72131 is "Computed tomography, lumbar spine; without 
contrast material." 
 
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 the records show that two different 
CT exams were done on 11/11/21.  
 First, a CT of the lumbar spine - CPT 72131 - was done, and then a CT of the hip - CPT 73700 was done on the 
same date. Each exam was interpreted by the same person. There was no second CT of the lumbar spine done. 
 
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 additional imaging services (procedure code 72131) provided to the enrollee on November 11, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the auricular stimulator. 
  You asked the Plan to pre-approve the auricular stimulator. You say that this is not 
experimental/investigational and medically appropriate and necessary. You say that the documentation 
provided should be reviewed and coverage reconsidered. The Plan denied your request. The Plan says auricular 
nerve stimulation is not covered, as it is not considered to be an implanted peripheral nerve stimulator by 
Medicare's definition. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.    
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular 
stimulator have not been met. Based on this information, we decided that Medicare rules for coverage of the 
auricular stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
auricular stimulator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography (procedure code 75726) provided to the enrollee 
on July 16, 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 it cannot be determined if the 59 modifier was used appropriately. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
operative report does not support billing CPT 75726 with modifier -59 - Distinct Procedural Service. This 
procedure would be inclusive to CPT 37243 Vascular embolization or occlusion, inclusive of all radiological 
supervision and interpretation, as it is (per CPT code description) "inclusive of all radiological supervision and 
interpretation".  Therefore, this procedure would not be covered. 
 
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 angiography (procedure code 75726) provided to the enrollee on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 7 and 10. 
 
You asked the Plan to pre-approve the crowns. You say that you need these crowns. The Plan denied your 
request. The Plan says there are no medical needs for these crowns. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crowns 
when the services are medically necessary and reasonable.  
 
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 crowns. Our reviewer says that 
crowns (D2740) for tooth #'s 7 and 10 are not medically reasonable and necessary. Our physician reviewer 
found the x-ray shows heavy incisal wear to the anterior teeth from attrition due to a loss of posterior occlusal 
support. The Plan provisions allow for crowns where there is loss of structure due to pathologic destruction due 
to trauma or caries. Our reviewer found that the present case is clearly the result of years of occlusal wear on 
the anterior teeth due to the loss of the posterior chewing teeth. Our physician reviewer also found that as such 
the Plan would not consider it necessary to place crowns on tooth #'s 7 and 10 despite the loss of structure as 
the loss has been incurred over a long period of time from wear and grinding. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2740) for tooth #'s 7 and 10.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the enrollee does not have documented skilled 
nursing needs or documented skilled therapy needs. The enrollee is ambulating household distances and 
tending to ADLs with minimal supervision. The enrollees care needs, as a practical matter, can be provided at 
a lower level 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 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: 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 you would like reconsideration because 
the LTACH admission is medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage for LTACH admission. 
 
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 you appear to be stable and do not require additional acute care hospital services and 
should be appropriate for a lower level of care as soon as arranged. You do not require services at the LTACH 
that are not already available at the current facility or a lower level of care. Transfer/admission to LTACH is 
not medically necessary as it would not be clinically advantageous at this time. 
 
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 laboratory services (83550, 83540, 83695, 86141, 80061, 
82172, 82306, 82728) provided on July 16, 2020. 
 
You asked the Plan to pay for laboratory services. You say that you did not receive the diagnosis code needed 
to file this timely. The Plan denied your request. The Plan says this claim was received more than a year after 
the service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 
 
 
 The record shows that a claim for laboratory services was not filed until November 2, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for laboratory services (83550, 83540, 83695, 86141, 80061, 82172, 
82306, 82728) provided on July 16, 2020.
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 does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. Her wound 
care needs acute hospital attention. She needs routine physical therapy and occupational therapy that can be 
provided in a skilled nursing 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 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 the laboratory services (81230, 81240, 81241, 81249, 81291, 
81408, and 81335) provided on July 2, 2021. 
 
You asked the Plan to pay for the laboratory 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 laboratories shall not report multiple individual CPT 
codes describing the component test results. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81230, 81240, 81241, 81249, 81291, 81408, and 81335) provided on July 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you cannot walk without assistance. The 
Plan denied your request. The Plan says the Skilled Nursing Facility (SNF) services you are requesting do not 
meet the requirements for approval. 
 
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 the SNF services. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. 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. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-
approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110 x 2) provided from May 7, 2021, to 
December 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that it is your understanding that the plan covers 2 
cleanings and 2 exams, plus $500 in dental work each year. You also say that you should not have to pay for 
these services. The Plan denied your request. The Plan says the benefit maximum of $500 was reached prior to 
the processing of the claim for the services in this case. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the benefit maximum of $500 has been 
exhausted. The record shows that the Plan paid $158 for services received on April 28, 2021, $258 for services 
received on May 27, 2021, and $84 for services received on May 24, 2021. $158 + $258 + $84 = $500. 
Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110 x 2) provided from May 
7, 2021, to December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMDx testing services provided on June 17, 2021. 
 You asked the Plan to pay for the testing services. You say that the testing reduces the number of unnecessary 
biopsies. The Plan denied your request. The Plan says a significant interval increase in the prostate specific 
antigen (PSA) level was not documented. 
 
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. 
 
We looked at the file and the rules. The records show the test screens for gene expressions used to determine 
the likelihood of prostate cancer upon biopsy. Medicare does not cover this test for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the SelectMDx testing services provided on June 
17, 2021.