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

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service January 4, 
2022. 
 
You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99284 is bundled into payment for code 99285. 
 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 99284 
is a column II code to column I code 99285. 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 99284 billed for date of service January 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from June 15, 
2022 to July 14, 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 the services were not medically necessary. 
 
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 the enrollee did not qualify for SNf coverage. The enrollee did not have any 
documented skilled nursing or skilled therapy needs. Daily skilled services were not required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs, 
custodial and intermittent, could, as a practical matter, 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 pay for skilled nursing facility (SNF) care provided from June 15, 2022 to July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation feature and the expandable 
controller, electronic connections, and harness requested for use with an approved power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller and related components. You say that it is felt that 
the requested items should be approved. The Plan denied your request. The Plan says all was approved aside 
from the expandable controller which exceeds the enrollee's needs. 
 
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 expandable controller and related 
components. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the patient does not require non-proportional input devices (e.g., sip 
and puff, head array, etc). The patient does not require a separate display (i.e., for alternate control devices), 
other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The patient has 3 power options of tilt, recline, and power elevating leg rests 
but the patient does not need to control the power options through a joystick. The patient's upper extremity 
strength and function support that the patient can control any power options through their own switches. 
 
The requested power seat elevation feature is statutorily noncovered. 
 
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 expandable controller and related components have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the power seat elevation feature and the expandable 
controller, electronic connections, and harness requested for use with an approved power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specimen validity testing (83789) billed for date of service 
June 8, 2022. 
 
You asked the Plan to pay for validity testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 validity 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 specimen validity testing (83789) billed for date of service June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64493 and 64494 billed for date of service 
December 29, 2021. 
 You asked the Plan to pay for procedure codes 64493 and 64494. You say that you disagree with the denial. 
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 codes 64493 and 64494 is 1. The MAI value for these codesis 2. You billed 2 
units each of code 64493-LT, 64493-RT, 64494-RT and 64494-LT; exceeding the MUE. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 64493 and 64494 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 64493 and 64494 billed for 
date of service December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the cost-sharing amount applied to 2 ostomy skin barriers 
provided on July 11, 2022. 
 
You asked the Plan to adjust the cost-sharing amount applied to the ostomy skin barriers. You say that the Plan 
is processing the claim incorrectly and has not paid their proper share. 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 a 20% 
coinsurance for prosthetic devices and related supplies.  
 
The records show that the Medicare allowed amount for each ostomy skin barrier was $6.23. You have been 
asked to pay a 20% coinsurance for each of the ostomy skin barriers. This item falls within the prosthetic 
devices and related supplies benefit category. 20% of the allowed $6.23 is $1.25. You were asked to pay $1.25 
for each of the ostomy skin barriers billed with code A4411. 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 adjust the cost-sharing 
amount applied to 2 ostomy skin barriers provided on July 11, 2022.  
 
Please note, our decision only applies to claim number 22256M000100 as was referenced in your original 
appeal request. The additional information you submitted to us directly included documentation for other dates 
of service. Please contact the Plan if you wish to initiate appeals for different claims, or to inquire about other 
appeals under review at the Plan level. 
 
Please also note, the non-contract provider is required to accept as payment in full amounts applicable in 
Original Medicare. If you have already paid the provider the full amount they billed, please contact them 
directly for reimbursement of any amounts paid beyond the allowed amount. If the provider is refusing to 
accept the applied allowed amounts as payment in full, you can contact the Denver Centers for Medicare and 
Medicaid Services (CMS) Regional Office at 303-844-4024.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service February 10, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 0037U is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 0037U is targeted genomic sequence analysis, solid organ 
neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the file shows that the 
specimen was not collected on the billed date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient services provided from September 7, 2021, through 
September 22, 2021. 
 
You asked the Plan to pay for the inpatient hospital care. You say that these two admissions should both be 
paid separately. The Plan denied your request. The Plan says that the enrollee was readmitted with the same 
condition within 30 days so separate payment cannot be made for the second admission. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 inpatient hospital care. Our reviewer 
says that the documentation supports separate payment for the second inpatient admission in this case. Our 
physician reviewer found the enrollee presented to the emergency department on September 7 with increased 
shortness of breath, vomiting, tachycardia, and confusion. She was treated for exacerbation of chronic 
obstructive pulmonary disease (COPD). She required IV antibiotics, supplemental oxygen, IV steroids and 
nebulizer treatments. Her condition stabilized and improved. She was discharged when medically stable on 
9/22/2021. She had been admitted 8/6/2021 from assisted living with syncope and pneumonia. Though the two 
admissions were for similar conditions, the readmission was not the result from a premature discharge from the 
same hospital.  
 
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 inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient services provided from September 7, 2021, through September 22, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical visits billed for date of service June 6, 2022. 
 
You asked the Plan to pay for medical visits. You say that the services at issue have been billed correctly for 
payment. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the denied codes are not supported in the case record. Specifically, a review of the file shows that 
the claim was not billed with condition code G0. Billing multiple medical visits in the same day requires this 
condition code. Based on this information, we decided that Medicare rules for coverage of medical visits have not been met. Therefore, we decided that the Plan does not have to pay for medical visits billed for date of 
service June 6, 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 need IRF care to build up your strength before 
being released. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF 
services do not meet the requirements for approval. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on May 28, 
2022. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says a valid proof of delivery 
was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. A delivery ticket was not submitted with the case file, 
and the provided packing slip is from April 29, 2022. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the durable medical equipment (DME) provided on May 28, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provide on July 14, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that the medical records do not show Medicare dental 
coverage criteria is met. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for an emergency 
department visit provide on July 14, 2022.  
 
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: 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 admission to IRF care is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. A request for skilled nursing facility (SNF) can be reviewed if submitted. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service February 8, 
2022. 
 
You asked the Plan to pay for procedure code 93010. The Plan denied your request. The Plan says payment for 
code 93010 is bundled into payment for code 32110.  
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 93010 
is a column II code to column I code 32110. 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 93010 billed for date of service February 8, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (80307) billed for date of service February 1, 
2022. 
 
You asked the Plan to pay for drug testing. You say that the services at issue were billed correctly for payment. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 80307 is: Drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service. 
 
We find that CPT code 80307 is not supported in the medical record. Specifically, the results of the testing at issue have not been provided for review. We cannot verify the services rendered. Based on this information, we 
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing (80307) billed for date of service February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and a radiologic examination of the spine, 
lumbosacral provided on July 12, 2022. 
 
You asked the Plan to pay for the office visit and a radiologic examination of the spine, lumbosacral. The Plan 
denied your request. The Plan says under the Medicare rules the request for chiropractic services other than 
manual manipulation is not a covered benefit because only manual manipulation furnished by chiropractor for 
treatment of subluxation is covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit and a radiologic examination of the spine, lumbosacral 
provided on July 12, 2022.