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

 
We decided that the Plan does not have to pay for procedure codes 93308, 93325, and 93321 billed for date of 
service August 17, 2022. 
 
You asked the Plan to pay for procedure code 93308, 93325, and 93321. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 93308, 
93325, and 93321 are bundled into payment for code 33016. 
 
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 codes 
93308, 93325, and 93321 are column II codes to column I code 33016. 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 codes 93308, 93325, and 93321 
billed for date of service August 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the prolonged evaluation and management service rendered on May 19, 
2022. 
 
You asked the Plan to pay for these services. You say that the services were billed correctly. The Plan denied 
your request. The Plan says that the claim was billed with the incorrect place of service code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the claim was incorrectly billed with place of service (POS) 
code 31 for a skilled nursing facility (SNF); however, the file shows that the services were performed in a SNF. 
The facility at which the services were rendered is registered as a SNF. The Plan has not provided any 
documentation to support that the claim is not payable as billed. Therefore, we decided that the Plan has to pay 
for the prolonged evaluation and management service rendered on May 19, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis starter pack. 
 
You asked the Plan to pre-approve Eliquis. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis starter pack.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lamictal tablets. 
 
You asked the Plan to pre-approve Lamictal. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lamictal tablets.  
 
Benefits for Lamictal may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant on tooth #7 (D6010) and guided 
tissue regeneration on tooth #7 (D4266). 
 
You asked the Plan to pre-approve the implant and tissue regeneration. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says an endosteal implant (D6010) and guided 
tissue regeneration (D4266) are not covered by your dental benefits. 
 
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 an 
endosteal implant on tooth #7 (D6010) and guided tissue regeneration on tooth #7 (D4266).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Remote monitoring of physiologic parameter provided on 
August 29, 2022. 
 
You asked the Plan to pay for Remote monitoring of physiologic parameter. You say that you are appealing the 
claim payment denial. 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 Remote monitoring of 
physiologic parameter provided on August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specimen validity testing provided on August 3, 2022. 
 
You asked the Plan to pay for specimen validity testing. You say that this testing is vitally necessary. The Plan 
denied your request. The Plan says the use of the -59 modifier is not supported for this code. 
 
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.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the record does not support that this specimen validity testing was separate and distinct 
from the drug testing performed on this date of service. Based on this information, we decided that Medicare 
rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan 
does not have to pay for specimen validity testing provided on August 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 5, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 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 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that inpatient psychiatric care is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for inpatient psychiatric 
care have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer says that inpatient psychiatric care is not medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has not been shown to be a danger to self or others. It is unclear if the enrollee 
has auditory or visual hallucinations. The enrollee is noted to be cooperative and compliant with treatment 
while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
gradient pressure pneumatic appliance, half leg (E0673) provided March 29, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you would like to 
appeal the decision to not pay for certain therapies instrumental in reducing the risk of post-operative 
complications. The Plan denied your request. The Plan says pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance, half 
leg (E0673) provided March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of the Minuteman G3R Interspinous 
device to L3-L4 (22612). 
 
You asked the Plan to pre-approve the Minuteman G3R Interspinous device. You say that implantation of the 
Minuteman G3R Interspinous device to L3- L4 is medically necessary. The Plan denied your request. The Plan 
says interspinous-interlaminar fusion surgery and the devices used for it remain experimental for use. More 
research is needed to show safety and efficacy of the procedure and the devices. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the Minuteman G3R Interspinous device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the implantation of the Minuteman G3R Interspinous device to L3-L4 (22612).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service February 22, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says these codes are 
included in the facility payment and are not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic continuous glucose monitor (CGM). You say that the enrollee 
has type 2 diabetes and is using Basaglar insulin 3 times daily. The enrollee has had an in person visit within 
the last 6 months. Therefore, the enrollee would be eligible for a CGM. The Plan denied your request. The Plan 
says the available medical records do not show the enrollee requires frequent adjustment based on their blood 
glucose testing results. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 CGM. Our physician reviewer found 
the provided medical records do not document that the enrollee's insulin treatment regimen requires frequent 
adjustment by the enrollee on the basis of BGM or CGM testing results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a CGM.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Breztri. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Breztri.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on January 20, 2022, billed 
with codes 99291 and 99292. 
 
You asked the Plan to pay for the critical care services. You say that this should be paid in full. The Plan 
denied your request. The Plan says no separate payment can be made for the critical care services. 
 
The Plan follows Medicare rules. Medicare rules say that only services unrelated to a minor procedure with a 
10-day global period can be separately paid when modifier -25 is used.  
 
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 critical care services. Our reviewer says 
that the documentation does not support separate payment for critical care services along with code 36556. Our 
physician reviewer found the medical records does not support the use of modifier -25 as there is no separately identifiable service. T medical record should include separate documentation for these services provided, which 
was not found.  Also, the documentation does not include information of time spent providing critical care, and 
what procedures were performed. 
 
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 critical care services have not been met. Therefore, we decided that the Plan 
does not have to pay for the critical care services provided on January 20, 2022, billed with codes 99291 and 
99292.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0080U) provided on June 20, 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 service. 
 
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. No lab 
results were provided for the service at issue. Therefore, we decided that the Plan does not have to pay for lab 
services (0080U) provided on June 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from July 25, 2022, to 
July 27, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 25, 2022. The NOA was not received by the Plan until March 23, 
2017. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from July 25, 2022, to July 27, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the patient programmer for use with an implanted programmable 
neurostimulator provided on October 22, 2021, billed with code L8681. 
 
You asked the Plan to pay for the patient programmer. You say that this was approved with this code, which 
allows one unit. The Plan denied your request. The Plan says that this was provided out-of-network and was 
not ordered by a network provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a valid denial rationale in this case. The claim denied 
based the number of units, which was not clearly supported and not used by the Plan in its appeal decision. The 
appeal rationale was that this was provided out-of-network without authorization. However, the appellant 
submitted evidence showing that the Plan's agent issued an approval notice for this code which was sent 
directly to the out-of-network provider. As this was approved by the Plan, we find that the denial of payment is 
not supported. Therefore, we decided that the Plan has to pay for the patient programmer for use with an 
implanted programmable neurostimulator provided on October 22, 2021, billed with code L8681.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air transportation provided in the Dominican Republic on 
May 26, 2022. 
 
You asked the Plan to pay for air transportation. You say that you were uncomfortable having surgery in the 
Dominican Republic so took a flight back to the United States. The Plan denied your request. The Plan says 
transportation back to the United States from another country is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that services performed outside of the United States 
are not covered except in certain, specified circumstances. The Plan provider worldwide urgent and emergency 
care coverage. However, the Plans benefits specifically exclude transportation back to the United States from 
another country. 
 
We looked at the file and Medicare rules. This transportation from the Dominican Republic back to the United 
States is not covered by Medicare and is specifically excluded from the Plans worldwide coverage benefits. 
Based on this information, we decided that Medicare rules for coverage of air transportation have not been met. 
Therefore, we decided that the Plan does not have to pay for air transportation provided in the Dominican 
Republic on May 26, 2022.