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

 
We decided that the Plan does not have to pay for procedure codes 95907 and 95886 billed for date of service 
August 29, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed codes cannot be verified. 
 
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 95907 is nerve conduction studies; 1-2 studies. The 
definition of code 95886 is 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). We find that CPT codes 95907 and 95886 are not supported in the medical record. 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 codes 95907 and 95886 billed for date of service August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595), provided on 
September 2, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the items are medically necessary. 
The Plan denied your request. The Plan says there is no evidence to support the ordering provider ordered the 
service. 
 
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. The medical records do not indicate this item was discussed or ordered. 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 electrical stimulator supplies (A4595), provided on September 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on August 25, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for genetic testing provided 
on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
provided on September 21, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination (92014). You say that you did not 
get a full examination, therefore, you should not be responsible for the follow up appointment. 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 $50 
copayment for Medicare-covered visit. 
 
You have been asked to pay a $50 copayment for a medical eye examination (92014). This item/service falls 
within the Medicare-covered visit benefit category. 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 waive the copayment for a 
medical eye examination (92014) provided on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ILR (CPT code 33285). 
 
You asked the Plan to pre-approve the ILR. You say that the ILR is medically necessary. The Plan denied your 
request. The Plan says the ILR is not medically necessary. 
 
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 ILR. Our physician reviewer found 
there is insufficient documentation to support the medical necessity for insertion of an ILR in this enrollee's 
clinical management. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the ILR (CPT code 33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on October 07, 2022. 
 
You asked the Plan to pay for a nursing facility care visit. You say that there is a medical necessity pre-
established with the enrollee and the facility for them to provide the required services. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility care 
visit provided on October 07, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electric nerve stimulation provided on August 
7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for transcutaneous electric nerve stimulation. You say that these services were 
medically necessary. The Plan denied your request. The Plan says these services have been correctly denied. 
 
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. Transcutaneous electrical nerve stimulator is also not a covered benefit. Therefore, we decided that the Plan 
does not have to pay for transcutaneous electric nerve stimulation provided on August 7, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were following the discharge instructions from 
the hospital. The Plan denied your request. The Plan says unauthorized, out-of-network care is not covered. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 office visit. Our reviewer says that the records do not indicate that the care 
provided was medically necessary. Our physician reviewer found the enrollee was seen for a lab draw follow-
up. It would have been medically reasonable to delay the services until the enrollee returned to their service 
area. 
 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 office visit have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for the office visit. Therefore, we decided that the Plan does not 
have to pay for an office visit provided on August 9, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says the request for approval of an IRF does 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 the enrollees 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 the enrollee 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 13, 2021, 
to December 18, 2021 at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J15.6. 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 services at the DRG originally billed. Our 
reviewer says that the submitted records do not support the billing of diagnosis code J15.6. Our physician 
reviewer found the enrollee was admitted to the hospital with worsening shortness of breath and cough. She 
was diagnosed with and treated for pneumonia seen on a chest x-ray. The diagnostic tests did not indicate the 
pathogen responsible for the pneumonia was a gram-negative bacteria. The documentation does not indicate 
that the diagnostic work-up and treatment ordered by the treating medical providers supported a diagnosis code 
J15.6.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 13, 2021, to December 18, 2021 at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve evaluation and management service visits (99499). 
 
 You asked the Plan to pre-approve evaluation and management service visits. You say that you have a long-
standing history of surgery, hospitalization and complications with bowel obstruction. You received a letter 
advising that your provider was leaving and would no longer be in network with your plan as of January 1, 
2023. The Plan denied your request. The Plan says your last visit with your previous provider was July 25, 
2022, and there was no active course of treatment. The Plan also says that they will redirect you to three in-
network colorectal providers that are in the allowable distance from your home. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
We looked at the file and Medicare rules. The records show that your last visit with your previous provider was 
July 25, 2022. The records also show that there was no active treatment from that provider. There are in-
network providers available for you. Based on this information, we decided that Medicare rules for coverage of 
evaluation and management service visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve evaluation and management service visits (99499).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on August 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services have been met. There 
was no physician order for testing 22 or more drug classes. Therefore, we decided that the Plan does not have 
to pay for lab services (G0483) provided on August 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not able to walk and are not getting better. 
You say that you are not ready to go home, and you need admission to a SNF.  The Plan denied your request. 
The Plan says based on Medicare guidelines, the SNF services you requested do not meet the requirements for 
approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. Your 
care can be managed currently in the inpatient rehabilitation facility with a transition to a home or community 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 38792-59-RT billed for date of service June 
6, 2022. 
 
You asked the Plan to pay for code 38792-59-RT. You say that this service was medically necessary. The Plan 
denied your request. The Plan says procedure code 38792-59-RT is considered inclusive to code 38900-RT, 
and the use of the 59 modifier is not supported to allow for separate payment. All other procedure codes have 
been paid. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for code 38792-59-RT Our reviewer says that 
the use of the 59 modifier with code 38792-59-RT is not supported. Our physician reviewer found according to 
coding rules and NCCI edits, 38792 is included in the main procedure reported with CPT code 38900. Since 
the procedures were performed on the same anatomical location, modifier 59 is not appropriate.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 38792-59-RT have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 38792-59-RT billed for date of service June 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 16, 2022, to 
June 14, 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 May 16, 2022, to June 
14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (44143) provided on July 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 44143 is "Colectomy, partial; with end colostomy and 
closure of distal segment (Hartmann type 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 use of code 44143 is 
not supported by the records provided. Our reviewer found that a colectomy with end colostomy and closure of 
distal segment was not performed. The record does state that a resection of the colon with anastamosis and 
small bowel resection with ileostomy were performed, however, these are separate procedures and should not 
be reported with CPT code 44143. 
 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 the services (44143) provided on July 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 28, 2022, to 
June 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. 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 looked at 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 have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from May 28, 2022, to June 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99205 billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided for review. The 
Plan denied your request. The Plan says the service was not billed as required. 
 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 99205 was billed on the same date as code 45331, performed by the same physician. 
CPT code 99205 was not billed with a modifier to indicate the service was significant and separate from the 
procedure performed. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99205 
billed for date of service April 5, 2022.