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

 
We decided that the Plan does not have to pay for the lab services billed for date of service February 3, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the 
coverage criteria have been met. The medical records provided were from a hospital visit in May of 2021. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services billed for date of service February 3, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided from October 28, 2021, to 
November 4, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient services at the DRG originally billed. You say that this claim and 
the billed diagnoses were appropriate and should be paid at the DRG originally billed. The Plan denied your 
request. The Plan says that this claim was paid at a lower DRG appropriately. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan provided very limited information in its case file submitted 
to us. The only denial information that the Plan provided indicated that "the claim should have been submitted 
under a different DRG because the original diagnosis procedure and/or disposition wasn't supported by the 
medical records."  This is problematic for several reasons.  First, the Plan has failed to indicate which diagnoses 
or procedures billed were not supported.  In addition, the Plan indicates in its limited submission to us that this 
determination was made based on a review of the medical records.  However, the Plan has failed to provide any 
medical records at all in the file it submitted to us.  Without medical records, we cannot determine if the Plan's 
denial was appropriate.  It is not clear if the Plan even had such records in its possession when it made this 
determination, bringing into question the legitimacy of the denial.  The burden is on the Plan to provide 
sufficient documentation supporting its denial.  It has failed to do so in this case. Therefore, we decided that the 
Plan has to pay for inpatient hospital services provided from October 28, 2021, to November 4, 2021, at the 
Diagnosis Related Group (DRG) originally billed.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87503, 87634, and 87631 billed for date of 
service August 3, 2021. 
 
You asked the Plan to pay for procedure codes 87503, 87634, and 87631. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for code 87634 is bundled into payment for 
code 87631. The Plan also says that respiratory panels with more than five respiratory pathogens performed are 
not a covered benefit. 
 
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 87634 
is a column II code to column I code 87631. This claim has not been billed with an appropriate modifier to 
bypass the edit. Code 87631 is not covered. The MUE for CPT code 87503 is 1. The MAI value for this code is 
3. You billed 2 units of this code, exceeding the MUE. 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 codes 87503, 87634, 
and 87631 billed for date of service August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair. 
 
You asked the Plan to pre-approve a group 2 power wheelchair. The Plan denied your request. The Plan says 
this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 power wheelchair is covered for the 
indications established in the applicable LCD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 2 power wheelchair. Our 
reviewer says that the requested group 2 power wheelchair is not medically reasonable and necessary. Our 
physician reviewer found that the record does not show that the enrollee is unable to use a manual wheelchair 
in the home, and therefore a power wheelchair is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 2 power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit (99205) provided on  
August 1, 2022. 
 
You asked the Plan to pay for a new patient office visit. You say that you would like the claim reprocessed as 
this was a new patient visit for dental oncology. The Plan denied your request. The Plan says the members 
claims history indicates another new patient E&M visit (99203) was reported on claim number 
820221270241785 for date of service May 6, 2022. 
 
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 99205 is a new patient for an office visit or other 
outpatient visit involving evaluation and management. The visit involves a high level of medical decision 
making and/or the provider spends 6074 minutes of total time on the encounter on a single date. 
 
We find that CPT code 99205 is not supported in the medical record. Specifically that code 99205 is not 
supported as another new patient code (99203) was billed by the same provider less than three years before on 
May 6, 2022. The enrollee is no longer a new patient with this provider; therefore code 99205 is not supported. Based on this information, we decided that Medicare rules for coverage of a new patient office visit have not 
been met. Therefore, we decided that the Plan does not have to pay for a new patient office visit (99205) 
provided on August 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on April 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that this service is needed based on medical necessity and 
is asking the plan to reconsider payment. 
 The Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
Therefore, the decision is upheld. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for drug testing provided on April 21, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman interspinous device. 
 
You asked the Plan to pre-approve the Minuteman interspinous device. You say that the clinical documentation 
provided supports the medical necessity and clinical appropriateness of the requested procedure. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Minuteman interspinous device in 
the setting of low back pain has not been demonstrated in the peer-reviewed literature. 
 
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 Minuteman interspinous device. 
Our reviewer says that the Minuteman interspinous device is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Minuteman interspinous device is experimental, and 
more research is needed. 
 
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 Minuteman interspinous device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Minuteman interspinous device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99232 and 93750 billed for date of service 
May 23, 2022. 
 
You asked the Plan to pay for procedure codes 99232 and 93750. You say that this should be covered The Plan 
denied your request. The Plan says payment for code 99232 is bundled into payment for code 99222 and 93750 
was previously paid. 
 
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 99232 
is a column II code to column I code 99222. 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. The rules also say 
that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are 
denied. The file includes evidence that code 93750 was reimbursed by the Plan on June 24, 2022. There is no 
evidence presented to support that the billed services were provided twice on the same date. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99232 and 93750 billed for date of service May 
23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met 
and the enrollee can receive the services they need in another setting like at a skilled nursing facility (SNF). 
 
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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. There are no nursing needs documented. At 
the current functional level, the enrollee does not need 3 hours a day at 5 days a week of therapies with 
multidisciplinary approach in an IRF. 
 
The documentation does not support medical necessity for admission to an IRF. The enrollee has no medical 
complexity, and no rehabilitation nursing needs other than routine nursing care. While the enrollee may benefit 
from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely met in an 
alternate and low intensity setting such as in a SNF. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis (L3761), provided on July 8, 2022. 
 
You asked the Plan to pay for the elbow orthosis. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the documentation submitted did not include a valid physician 
order. 
 
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 physician order in this case. The enrollee's treating physician confirmed 
they did not order this item. 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 elbow orthosis 
(L3761), provided on July 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR panel provided on April 1, 2022, billed with 
codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87640, 87641, 87651, 87653, 87661, 
and 87798. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you are an independent diagnostic 
laboratory that tests pathology, medication management and toxicology samples sent from clinics and 
providers for patients they have determined require such testing. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. PCR testing is considered unproven and not 
medically necessary 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the urine PCR panel 
provided on April 1, 2022, billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 
87640, 87641, 87651, 87653, 87661, and 87798.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap services 
coded 15734 provided on April 26, 2021. 
 
You asked the Plan to pay for the muscle, myocutaneous, or fasciocutaneous flap services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
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 15734 is muscle, myocutaneous, or fasciocutaneous flap; 
trunk. 
 
 We find that CPT code 15734 is not supported in the medical record. Specifically, the operative report did not 
include documentation of muscle, myocutaneous, or fasciocutaneous flap from the trunk. Based on this 
information, we decided that Medicare rules for coverage of the muscle, myocutaneous, or fasciocutaneous flap 
services have not been met. Therefore, we decided that the Plan does not have to pay for the muscle, 
myocutaneous, or fasciocutaneous flap services coded 15734 provided on April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had back surgery and your medical and physical 
needs cannot be met at a lower level of care. The Plan denied your request. The Plan says the IRF services you 
are requesting 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the humerus fracture treatment rendered on June 11, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with a diagnosis code 
with the incorrect laterality. 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 humerus fracture 
treatment rendered on June 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service coded 
99443 provided on June 12, 2021. 
 
You asked the Plan to pay for the telephone evaluation and management service. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services billed are 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 99443 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 21-30 minutes of medical discussion. 
 
We find that CPT code 99443 is not supported in the medical record. Specifically, the documentation did not 
include documentation of the total time spent on patient care/medical discussion, consent by the enrollee for 
telemedicine services, or clear documentation of an evaluation and management service. Based on this information, we decided that Medicare rules for coverage of the telephone evaluation and management service 
have not been met. Therefore, we decided that the Plan does not have to pay for the telephone evaluation and 
management service coded 99443 provided on June 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services provided on July 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for vision services. You say that you have been with this provider since  
November 1, 2019, and you have never had any problems with claims denying. You also say that you need 
regular eye examinations because you have diabetes. The Plan denied your request. The Plan says you must 
receive your care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for vision services provided on July 13, 2022, by an 
out-of-network (OON) provider.