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

 
We decided that the Plan does not have to pay for the MRA, head; without contrast material(s) (CPT code 
70544) provided on October 24, 2021. 
 
You asked the Plan to pay for the MRA. 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. 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 70544 
is a column II code to column I code 70551. 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 the MRA, head; without contrast material(s) (CPT code 70544) 
provided on October 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 81479) provided on June 
29, 2021. 
 
You asked the Plan to pay for the laboratory service. 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 laboratory service have not been met. CPT code 81479 remains 
not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient 
when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in 
a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the 
specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on June 18, 2021, and received by the lab on June 22, 2021; therefore, the billed code 
cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. 
Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code 81479) provided 
on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service.  
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office 
consultation to be rendered by the out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 
12, 2021. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for this code is bundled into payment for code 
93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service November 12, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (E2365, K0823) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you have supplied a number of chairs for 
the referring provider and facility of which this patient resides. The Plan denied your request. The Plan says 
they confirmed with a participating provider that the out-of-network provider does not provide any specialty 
that the Plan's participating provider cannot provide. The Plan also says that they also confirmed that the 
participating provider can provide the service and has an appointment available within a week and is within the 
Medicare allowable distance and time. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
The requested provider in this case is not a network provider with the Plan. 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 pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a power wheelchair (E2365, K0823) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outdoor stair railing and a lift for a scooter. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an outdoor stair railing and a lift for a scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 9, 2021, through 
April 14, 2021. 
 You asked the Plan to pay for inpatient hospital care. You say that you submitted supporting documentation for 
reconsideration of DRG adjustment. The Plan denied your request. The Plan says the determination to remove 
secondary diagnosis code J96.01 (Acute respiratory failure with hypoxia) is upheld. 
 
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 J96.10, principal diagnosis code, defined as chronic 
respiratory failure, unspecified whether with hypoxia or hypercapnia]. 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 inpatient hospital care. Our physician reviewer found the documentation 
describes the patient as only requiring low dose oxygen support without significant distress which does not 
meet criteria for this diagnosis. Therefore, the provided documentation does not sufficiently support acute 
respiratory failure with hypoxia.  
 
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 care provided from April 9, 2021, through April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography, extremity, unilateral, radiological supervision 
and interpretation (CPT code 75710-26-XU), introduction of needle or intracatheter, upper or lower extremity 
artery (CPT code 36140-51-XU-RT), and thromboendarterectomy, including patch graft, if performed; deep 
(prounda) femoral (CPT code 35372-50-51) provided on July 12, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 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 found CPT code 75710 - Documentation submitted was reviewed and does not meet criteria. Operative report does not include 
documentation to support radiological supervision and interpretation was performed as a distinct service from 
CPT 35665. CPT 35665 would include radiological supervision to perform this procedure.  In this case, this 
procedure was unbundled from CPT 35665. CPT 36140 - Documentation submitted was reviewed and does not 
meet criteria. Operative reports describe a more comprehensive procedure, introduction of a catheter to the 
aorta, which has been approved. Therefore, this procedure would not be coded separately. CPT 35372 - 
Documentation submitted was reviewed and does not meet criteria. Operative report describes a deep femoral 
thromboendarterectomy including patch graft, which is part of a more comprehensive procedure, CPT 35661 
which has been approved. 
 
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 angiography, extremity, unilateral, radiological supervision and interpretation (CPT code 
75710-26-XU), introduction of needle or intracatheter, upper or lower extremity artery (CPT code 36140-51-
XU-RT), and thromboendarterectomy, including patch graft, if performed; deep (prounda) femoral (CPT code 
35372-50-51) provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reduction of osseous tuberosity (D7485). 
 
You asked the Plan to pre-approve a reduction of osseous tuberosity. You say that an osseous tuberosity 
reduction of the maxillary arch is needed to make the tuberosity less prominent/smaller. You also say the 
enrollee has an enlarged maxillary tuberosity that hangs down beyond the rest of her upper jaw which makes it 
difficult for a maxillary denture to fit properly. The Plan denied your request. The Plan says the service or item 
in question is not covered under the enrollee's contract under any normal circumstances. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
reduction of osseous tuberosity (D7485).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 22869) provided on 
September 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered 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. 
 
CPT code 81479 remains not supported. The place of service on the CMS-1500 form line 24B must reflect the 
location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory 
specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results 
submitted indicate the specimen was collected on August 25, 2021, and received by the lab on August 26, 
2021; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional 
information from the provider. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code 22869) provided on September 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99379 billed for date of service July 30, 
2021. 
 
You asked the Plan to pay for procedure code 99379. You say that these services were medically necessary and 
should be covered. The Plan denied your request. The Plan says no separate payment is made for this code. 
 
  The Plan must follow Medicare rules. Medicare rules say that that for procedure codes with a status indicator of 
'B' on the Medicare Physician Fee Schedule Database, payment is always bundled into payment for other 
services.  No separate payment is ever made for this procedure codes. Procedure code 99379 has a status 
indicator of B on the Medicare Physician Fee Schedule Database. 
 
We looked at the file and Medicare rules.  Therefore, we decided that the Plan does not have to pay for 
procedure code 99379 billed for date of service July 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided by an out-of-network 
provider on September 25, 2021, to October 1, 2021. 
 
You asked the Plan to pay for inpatient hospital services. You say that you would like the Plan to reprocessed 
and pay this claim. The Plan denied your request. The Plan says prior authorization was denied; therefore, 
services have been correctly denied. 
 
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 inpatient hospital services provided by 
Signing River Hospital on September 25, 2021, to October 1, 2021, have been met. Medical records were not 
provided to confirm if Medicare criteria have been met. Therefore, we decided that the Plan does not have to 
pay for inpatient hospital services provided by an out-of-network provider on September 25, 2021, to October 
1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services rendered on February 2, 2021. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that providers/suppliers have an obligation, under law, to 
conform to the requirements of the Medicare program. 
 
We looked at the file and Medicare rules. There is no documentation to support that the services were 
performed for the date of service at issue. 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 
telehealth services rendered on February 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the head or brain CT scan (CPT code 70450) provided on 
August 15, 2021. 
 
You asked the Plan to pay for the CT scan. 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. 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 70450 
is a column II code to column I code 70496. 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 the head or brain CT scan (CPT code 70450) provided on August 
15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76700) provided on 
November 4, 2021. 
 
You asked the Plan to pay for the abdominal 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. 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 76700 
is a column II code to column I code 93976. 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 the abdominal ultrasound (CPT code 76700) provided on 
November 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on May 27, 2021. 
 
You asked the Plan to pay for the SelectMDx testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says there was no documented result of prior 
prostate biopsy. 
 
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 test at issue in this appeal, the SelectMDx testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Additionally, the documentation submitted does not 
include any clinical information. There is insufficient information to determine why this testing was ordered, 
how the results will affect the member's treatment or if Medicare criteria for coverage have been met. 
Therefore, we decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on May 
27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolozone therapy. 
 
You asked the Plan to pre-approve Prolozone. You say that the service is medically necessary. The Plan denied 
your request. The Plan says this procedure is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that medical effectiveness of the above therapies has 
not been verified by scientifically controlled studies. Accordingly, reimbursement for these modalities should 
be denied on the ground that they are not reasonable and necessary. 
 
We looked at the file and Medicare rules. This procedure is not covered under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of Prolozone have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Prolozone therapy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the head or brain CT scan (CPT code 70450) provided on 
September 14, 2021. 
 
You asked the Plan to pay for the CT scan. 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. 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 70450 
is a column II code to column I code 70496. 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 the head or brain CT scan (CPT code 70450) provided on 
September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
device (CPAP). 
 
You asked the Plan to pre-approve the device.. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is not meeting the compliance standard that Medicare has defined. 
 
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the follow-up visit on 11/30/21 noted no significant issues except mask 
leak. You were advised of the importance of adherence to use. The adherence reports show that you were not 
using the device enough to be effective, and not using enough to meet Medicare criteria of at least 4 hrs/night 
for at least 70% of nights. 
 
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 device. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued use of a continuous positive airway pressure device (CPAP).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided June 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were 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 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 (81479) provided June 18, 2021.