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

 
We decided that the Plan does not have to pay for the lab services provided on March 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim should be covered. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
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 the lab services was not filed until May 10, 2022. 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 the lab services provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on June 27, 2022. 
 
You asked the Plan to pay for the consultation. You say that the provider did not disclose prior to completing 
that the procedure was not covered. The Plan denied your request. The Plan says the requested dental procedure 
code is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on June 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation without medical services 
provided on May 18, 2022. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation without medical services. The Plan denied 
your request. The Plan says a Marriage and Family Therapist is not eligible to bill Medicare for mental health 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist (MFT) is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist 
(MFT). Medicare says that a Marriage Family Therapist (MFT) is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation 
without medical services provided on May 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on July 20, 2022. 
 
You asked the Plan to pay for the chest x-ray (71045). You say that the procedure was rendered in the 
appropriate place of service and the claim should be reconsidered for payment. The Plan denied your request. 
The Plan says the incorrect POS was billed. 
 
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 71045 is radiologic examination, chest; single view. 
 
  We find that CPT code 71045 is not supported in the medical record. Specifically, the outpatient POS code was 
billed, but the records show the enrollee was an inpatient on this date of service. Based on this information, we 
decided that Medicare rules for coverage of the chest x-ray (71045) have not been met. Therefore, we decided 
that the Plan does not have to pay for the chest x-ray (71045) provided on July 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bevacizumab-awwb, biosimilar, (mvasi), 10 mg injections 
provided to the enrollee from June 3, 2022, through July 1, 2022. 
 
You asked the Plan to pay for the drug. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was experimental and investigational. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee has a diagnosis of metastatic endometroid adenocarcinoma who has been previously treated with the requested regimen. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare-approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature 
from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are 
not satisfied. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pay for Bevacizumab-awwb, biosimilar, (mvasi), 10 mg injections provided to the enrollee from June 3, 
2022, through July 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management provided on March 23, 
2022. 
 
You asked the Plan to pay for the hospital discharge day management. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the record does not support that this service 
was more than 30 minutes in duration. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not show 
that this discharge day management service was more than 30 minutes in duration. Based on this information, 
we decided that Medicare rules for coverage of the hospital discharge day management have not been met. 
Therefore, we decided that the Plan does not have to pay for hospital discharge day management provided on 
March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiology services provided to the enrollee on June 
15, 2022. 
 
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 the records do not support the services billed. 
 
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: 
 
CPT 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
CPT 95908:  
Nerve conduction studies; 3-4 studies 
 
CPT 95955: 
 
Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
 
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 the records do not support that 
CPT 95908 was rendered in this case. In this case, the enrollee underwent lumbar spine surgery and 
intraoperative neuromonitoring services were provided. The surgeon performed what is called pedicle screw 
testing. From a coding perspective, this procedure (pedicle screw testing) is inherent to the CPT code for 
elelctromyography (EMG) testing (as it's considered triggered EMG recording). The documentation provided 
did not support provision of a nerve conduction study (NCS) study otherwise. Therefore, this code was not 
appropriate for the services provided. For this reason, CPT 95886 is also not the most appropriate code to use, 
as a nerve conduction study was not performed. In terms of CPT 95955, the enrollee had a basic two channel 
electroencephalogram (EEG) done. This is below the minimum number of channels for performance of an 
EEG. As the minimum technical standards for this service were not met/satisfied, the code cannot be 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for neurophysiology services provided to the enrollee on June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology (uveal melanoma), mRNA, gene expression 
profiling by real-time RT-PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or 
formalin-fixed paraffin-embedded tissue, algorithm reported as risk of metastasis (81552) provided on June 7, 
2022. 
 
You asked the Plan to pre-approve genetic testing. You say that patients with a test result indicating high risk 
of developing metastasis can be followed with a higher intensity program, such as quarterly ultrasound, MRI or 
CT scans alternating with LFTs and consideration of adjuvant treatment interventions. The Plan denied your 
request. The Plan says records do not document any tests showing that you do not currently have metastases of 
your melanoma. The request 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 looked at the file and Medicare rules. Records do not show that the enrollee does not currently have 
metastases of her melanoma. Based on this information, we decided that Medicare rules for coverage of genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pre-approve oncology (uveal 
melanoma), mRNA, gene expression profiling by real-time RT-PCR of 15 genes (12 content and 3 
housekeeping), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, algorithm reported as 
risk of metastasis (81552) provided on June 7, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care service provided on March 28, 2022. 
 
You asked the Plan to pay for critical care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee was enrolled in hospice on this date of service so the Plan is not 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for critical care service provided on March 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99223) provided to 
the enrollee on May 31, 2022. 
 
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 the documentation does not support the high level of complexity for CPT 99233. 
 
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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
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 according to Medicare, CPT code 
99233 can be used for subsequent hospital care, per day, for the evaluation and management of a patient with at least 2 of the 3 key components: a detailed interval history, a detailed examination, medical decision making of 
high complexity.  Usually, the patient is unstable or has developed a significant complication or a significant 
new problem and takes approximately 35 minutes at the bedside or the patients hospital floor or unit. The 
records do not support this level of care. 
 
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 subsequent hospital care (procedure code 99223) provided to the enrollee on May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the platelet rich plasma (PRP) injections (0232T) 
paid for on March 31, 2022. 
 
You asked the Plan to reimburse you for the PRP injections. You say that an itemized statement was provided 
on September 6th. You also say that you should be reimbursed for these services. The Plan denied your request. 
The Plan says PRP injections are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 0232T is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PRP injections have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the platelet rich plasma (PRP) injections (0232T) paid for on March 31, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 16, 2021. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document 
the consent or declination date to consultations and the date of consultations in the patients medical record. If 
consultation with the attending or primary care physician is unsuccessful, document the patients medical chart 
with the date and manner of notification to the physician. There was no documented contact with the 
attending/primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on September 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is a medical necessity for you. The Plan 
denied your request. The Plan says rules for IRF care have not been met. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You continue to 
have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement. However, the available documentation doesnt support that you would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain functional status. 
 
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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 6, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652 and E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
criteria for the requested pneumatic compression device (E0652). 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has lymphedema extending onto the chest, trunk and/or abdomen. Because the base item E0652 is not covered, the 
related accessory coded as E0667 is also not covered. Therefore, we decided that the Plan does not have to pre-
approve a pneumatic compression device (E0652 and E0667).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement services (procedure code 97598) provided to the 
enrollee on April 8, 2022. 
 
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 the records do not support the services billed. 
 
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 97598 is "Debridement (eg, high pressure waterjet 
with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, 
devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound 
assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) 
surface area; each additional 20 sq cm, or part thereof (List separately in addition to code for primary 
procedure)." 
 
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 the medical record does not 
include documentation of Debridement open wound, including topical application(s), wound assessment, use of 
a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each 
additional 20 sq cm, or part thereof. Debridement cannot be verified. 
 
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 debridement services (procedure code 97598) provided to the enrollee on April 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) provided on October 
19, 2021. 
 
You asked the Plan to pay for the shingles vaccine. You say that the vaccine was medically necessary. The Plan 
denied your request. The Plan says the shingles vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) 
provided on October 19, 2021.  
 
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.