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

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service October 29, 
2021. 
 
You asked the Plan to pay for the billed code. You say that the enrollee was seen for a medically necessary 
procedure. The Plan denied your request. The Plan says the payment is included in the facility 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. 
 We find that CPT code 99153 is a technical component only code. The total relative value units for technical 
component only codes include values for practice expense and malpractice expense only. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99153 billed for date of service October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64447 and 01402 billed for date of service 
June 8, 2021. 
 
You asked the Plan to pay for procedure codes 64447 and 01402. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 64447 is bundled into payment for code 
01402. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that providers must report the actual number of units provided for each procedure code. 
We find that 162 units of CPT code 01402 are not supported in the medical record. when a 
block is placed before induction or after emergence, the time spent placing the block should not be added to the 
reported anesthesia time. Therefore, billed code 01402 with 162 units cannot be verified. 
 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. In this case, 
we have confirmed that code 64447 is a column II code to column I code 01402. While code 64447 was billed 
with modifier -59, the documentation does not show that the service billed with the -59 modifier is a distinct 
procedural service. 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 64447 and 01402 billed for date of service June 
8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Prolia. Our reviewer says that the 
requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires either a 
trial of zoledronic acid or a history of an osteoporosis-related fracture before they will approve Prolia. There is 
no indication that the enrollee has tried and failed zoledronic acid or has a history of an osteoporosis-related 
fracture. There is also no indication that zoledronic acid would likely be less effective or have adverse effects 
for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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 you are requesting inpatient rehabilitation services so 
you can return safely to your prior level of function and/or maximum potential. The Plan denied your request. 
The Plan says you can safely receive the services you need including custodial care and therapy, in other 
settings such as a skilled nursing facility (SNF), residential long term care facility, or home with home health. 
 
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 you have 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on August 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing distinguishes those at risk for prostate 
cancer. The Plan denied your request. The Plan says screening services without a valid diagnosis are not a 
benefit. 
 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. 
 
The file shows that a SelectMDx test was provided. The test at issue in this appeal was requested for screening 
purposes. There are no records from the enrollees treating physician to show the testing was ordered due to 
specific signs or symptoms of the enrollee. Testing is not considered necessary merely on the basis of a 
diagnosis code. Screening services such as pre-symptomatic genetic tests and services used to detect an 
undiagnosed disease or disease predisposition are not a Medicare benefit and are not covered. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on August 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services coded 97597 and 97598 provided 
on May 12, 2022. 
 
You asked the Plan to pay for the debridement 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. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 97597 and 97598 are not supported in the medical record. Specifically, the 
documentation submitted did not include documentation of 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; first 20 sq cm or less; therefore, code 97597 cannot be verified. Code 97598 is an add-on code 
that requires a primary service code. Since the primary code was not supported/not covered, this add-on code 
has not been billed with an appropriate primary procedure code and is therefore, not separately payable. 
Based on this information, we decided that Medicare rules for coverage of the debridement services have not 
been met. Therefore, we decided that the Plan does not have to pay for the debridement services coded 97597 
and 97598 provided on May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Therabody  RecoveryAir pneumatic compression 
device. 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested device will 
provide some relief of your ankle, foot and toe edema. The Plan denied your request. The Plan says you do not 
meet the coverage criteria for the requested item. You have not successfully completed a Plan supervised 
lymphedema self-management program. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve a Therabody  RecoveryAir 
pneumatic compression device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 35875 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the coding. The Plan 
denied your request. The Plan says the code is not valid for assistant at surgery services. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 35875. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
35875 billed for date of service May 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 9, 2022, to 
August 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 9, 2022, to August 
7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on June 
17, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the member did not 
receive the ordered equipment. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the medical records are dated December 17, 2020. This is over a year before the 
equipment was provided on June 17, 2022.  There is no evidence of recent medical records to indicate the medical necessity of the equipment in 2022. Therefore, we decided that the Plan does not have to pay for the 
electrical stimulator supplies (A4595) provided on June 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound (76642) provided on September 12, 
2022. 
 
You asked the Plan to pay for the breast ultrasound. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the breast ultrasound have not been met. CPT code 76642 was not 
billed in accordance with Medicare National Correct Coding Initiative Policy Medically Unlikely Edits (MUE). 
CPT code 76642 is not billed in accordance with Medicare National Correct Coding Initiative Policy. CPT 
code 76642 has an MUE value of 1, but billed 2 units. Therefore, we decided that the Plan does not have to pay 
for the breast ultrasound (76642) provided on September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99211 provided on February 3, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as 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 99211 is office or other outpatient visit for the evaluation 
and management of an established patient that may not require the presence of a physician or other qualified 
health care professional. 
 
We find that CPT code 99211 is not supported in the medical record. Specifically, this code was billed with 
modifier CR. The correct modifier to waive cost sharing should be modifier CS. The claim is not payable as 
billed. Based on this information, we decided that Medicare rules for coverage of the office visit have not been 
met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99211 provided on 
February 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit for COVID-19 testing (99211) provided on 
February 2, 2022. 
 
You asked the Plan to pay for COVID-19 testing. You say that this service was medically necessary and should 
be paid. The Plan denied your request. The Plan says this claim should be resubmitted with modifier CS in 
order to be processed 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. The rules say that the CS modifier should be 
submitted with an appropriate E/M code to bill for COVID-19 symptom and exposure assessment and 
specimen collection performed on and after March 1, 2020. 
 
We find that CPT code 99211 is not supported in the medical record. Specifically, the records show that this 
service was performed in relation to COVID-19 but was not billed with the necessary CS modifier. Based on 
this information, we decided that Medicare rules for coverage of COVID-19 testing have not been met. 
Therefore, we decided that the Plan does not have to pay for an office visit for COVID-19 testing (99211) 
provided on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99497 and 99498 billed for date of service 
March 18, 2022. 
 You asked the Plan to pay for procedure code 99497. The Plan denied your request. The Plan says the 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, we have confirmed that code 99497 is a column II code to column I code 99223. This code has not 
been billed with an appropriate modifier to bypass the edit. Because primary code 99497 is not payable, the 
add-on code 99498 is also not payable. 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 99497 and 99498 billed for 
date of service March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatments (98940). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says the requested services are not medically necessary as you do not 
have a diagnosis of a subluxation of the spine demonstrated by x-ray or physical exam.  
 
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.  
 
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 these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that you have diagnoses of 
cervicalgia and low back pain, unspecified. A computed tomography (CT) scan of the cervical spine provided 
on October 6, 2022 does no document a subluxation of the spine. The case file contains Emergency Department 
notes for staple removal and a fall. The medical records in this case do not demonstrate a subluxation of the 
spine by x-ray or physical exam. The documentation in the case file does not support that chiropractic 
manipulative treatments are medically reasonable and necessary for you in this case. 
 
  
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve chiropractic manipulative treatments (98940).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 3, 2021. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build-up (D2950) provided by a participating 
provider. 
 
You asked the Plan to pre-approve a core build-up. You say that this dental work is medically necessary. The 
Plan denied your request. The Plan says the medical criteria for D2950 have not been met. 
 
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. The Plan covers a core build-
up 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 a core build-up. Our physician reviewer 
found the Plan would require that there is significant missing structure to support the need for a buildup under a 
crown. As the majority of the tooth structure is still intact, a core buildup would not be indicated or necessary. 
The Plan's criteria would not be met for a core buildup as requested. 
 
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 a core build-up have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a core build-up (D2950) provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tuberculosis test (86481) provided on June 7, 2022. 
 
You asked the Plan to pay for tuberculosis testing. You say that you were never asked if you wanted to have 
the tests done and you should not have to pay for this testing. The Plan denied your request. The Plan says 
laboratory tests performed as pre-employment screening and not for medical purposes are not covered. 
 
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. The testing services in this case were performed as part of a pre-
employment screening and were not provided in relation to the diagnosis or treatment of an illness or injury. 
Based on this information, we decided that Medicare rules for coverage of tuberculosis testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the tuberculosis test (86481) provided on 
June 7, 2022.