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

 
We decided that the Plan does not have to pay for the laboratory services provided on December 21, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered.  
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 was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on December 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on January 3, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(0037U) provided on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 95910, 95886, and 95937 
provided on August 27, 2021. 
 
You asked the Plan to pay for the medical services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the medical records do not 
support payment for the CPT codes 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 the billed codes are as follows: 
 
95910 -  Nerve conduction studies; 7-8 studies  
95886 -  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)  95937 -  Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
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 medical services as billed. Our reviewer says that the 
documentation does not support payment for the billed CPT codes. Our reviewer found for these codes that 
were billed, the medical record does not include a technical report to confirm nerve conduction studies as 
performed. In this case, verification of the billed codes cannot be made. 
 
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 medical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services coded 95910, 95886, and 95937 provided on August 27, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing services provided on January 19, 2022. 
 
You asked the Plan to pay for the laboratory testing services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says no separate payment is 
made for these laboratory services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory testing services provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 15, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and based on the 
information provided, it was determined these services were not urgent or emergent. 
 
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 laboratory services provided on October 15, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on February 15, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the code does not require a modifier. 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.  
 
 We find that CPT code G0463 has a status indicator of V. This code was billed with CPT code 86870, which 
has a status indicator of S. The claim information does not show that code G0463 was billed with a modifier to 
show that it was a significant and separately identifiable from the procedure. This means the claim is to be 
returned to the provider. Based on this information, we decided that Medicare rules for coverage of the services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient 
hospital services provided on February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraosseous radiofrequency ablation of the 
basivertebral nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the request is considered 
investigational. 
 
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 requested services. Our physician 
reviewer found that there are multiple plausible pathologic sources of significant pain generation. Overall, 
documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. The 
documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary or reasonable at this time. There is no compelling rationale or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the request for the 
intraosseous radiofrequency ablation of the basivertebral nerve at L2 and L3 vertebral bodies is not medically 
reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intraosseous radiofrequency ablation of the basivertebral nerve.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 19, 2022. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes billed 
are included in the dialysis rate. The Plan denied your request. The Plan says the services are the responsibility 
of the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services provided on November 23, 2021. 
 
You asked the Plan to pay for the x-ray services. You say that you disagree with the Plan's decision. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3.  
 
In this case, the MUE for CPT code 71046 is 2. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the x-ray 
services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services 
provided on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermatology office surgery visit provided on March 15, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dermatology office surgery visit. You say that the claim should be paid with 
your point-of-service benefit, and you were not told the services would need authorization. The Plan denied 
your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
dermatology office surgery visit. We found no exception that would require the Plan to pay for the dermatology 
office surgery visit. The record shows no prior authorization was obtained. Therefore, we decided that the Plan 
does not have to pay for the dermatology office surgery visit provided on March 15, 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 a medication assisted treatment to be provided by an 
OON provider. 
 
You asked the Plan to pre-approve a medication assisted treatment. You say that you need this treatment to be 
covered because it is necessary. The Plan denied your request. The Plan says the request is denied because 
there are providers available and accepting new patients within your network. 
 
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 medication assisted treatment to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy. 
 
You asked the Plan to pre-approve knee arthroscopy. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
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 knee arthroscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were being treated for loose body in the left knee. You presented with left knee 
pain. You have some fullness in the knee, with difficulty fully bending the knee or straightening it out. There is 
catching at times. The exam reveals range of motion of 10-118 degrees in the left knee. There are palpable 
loose bodies in the suprapatellar pouch. There is some tenderness in this area. There is some medial joint line 
tenderness. There is guarding on McMurrays maneuver. X-rays of the left knee reveals radiodensities in the 
suprapatellar pouch consistent with loose bodies palpable on exam; moderate medial joint space narrowing; 
patellofemoral osteophytes present. However, you have moderate osteoarthritis in the left knee corroborated by 
imaging. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. Despite having a diagnosis/condition (meniscal 
tear, loose bodies) that meets the criteria for the requested service, you also have a diagnosis (multi-
compartmental moderately severe osteoarthrosis) that is a contraindication for the procedure. Therefore, you do 
not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee arthroscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve knee arthroscopy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services provided on March 10, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to treat the enrollee's 
advanced cancer. The Plan denied your request. The Plan says the testing should be reported with code 81479. 
 
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 the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the testing services provided on March 10, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does not meet 
criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of your nursing medical and rehabilitation needs do require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. Your hospital course has been complicated with 
respiratory failure requiring intubation and chest tube placement. You do require treatment by multiple 
therapies, including physical therapy, speech therapy and occupational therapy, and an intensive rehabilitation 
therapy program at least three hours a day and five days a week, or 15 hours over seven consecutive days. You 
were noted to have 3/5 motor strength in the upper and lower extremities and require minimal assistance with 
bed mobility, transfers, and ambulation. You require moderate assistance with dressing and bathing and have 
had a decline in baseline level of function. Given your multiple co-morbidities and the need to monitor your 
respiratory status closely, you would benefit from the intensity of rehabilitation physician oversight provided in 
the acute inpatient rehabilitation setting. You also require rehabilitation nursing continued tube feeding. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 the genetic testing provided on February 11, 2022 billed with 
codes 81225, 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's decision. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 11, 2022 billed with codes 81225, 81227, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 
0032U, and 0033U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on January 10, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that charges are not required for preauthorization. 
The Plan denied your request. The Plan says the services were not urgent or emergent in nature. 
 
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 file shows that the enrollee was treated for cerumen (wax) impaction. The provider in this case is not a 
network provider with the Plan. The Plan had network providers available who could have provided the 
services at issue in this appeal. The Plan did not pre-approve the services at issue.  We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the physician services provided on January 10, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denied IRF services. The Plan 
denied your request. The Plan says the medical records received; the enrollee's condition does not meet 
Medicare guidelines. The enrollee does not have a complex medical condition. The enrollee does not need 
close supervision by a rehabilitation doctor. The enrollee does not need 3 hours of therapy per day or 15 hours 
per week. The enrollee's rehabilitation needs do not require an intensive team approach. The enrollee can safely 
receive the services they need in a less intensive setting like a skilled nursing facility. 
 
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. No acute nursing needs identified or 
documented. At the high current functional level, the enrollee does not need 3 hours a day 5 days a week of 
therapies. 
 
The lack of medical complexity and lack of nursing needs and high functional mobility do not support an acute 
hospital inpatient rehab admission with an interdisciplinary approach to rehabilitation care. Document does not 
support the medical necessity for admission to an IRF. The enrollee's rehab needs can be safely provided in an 
alternate and low intensity setting such as in-home with services. 
 
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.