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

 
We decided that the Plan does not have to pay for the genetic testing provided on July 12, 2022, billed with 
codes 81291, 81401, 81335, 81227, 81225, 81230, 81328, 81231, 81355, 81232, 81226, 81408, 81240 and 
81241. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
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 
July 12, 2022, billed with codes 81291, 81401, 81335, 81227, 81225, 81230, 81328, 81231, 81355, 81232, 
81226, 81408, 81240 and 81241.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an eye refraction (92015) provided on August 1, 2022. 
 
You asked the Plan to pay for an eye refraction (92015). You say that a refraction is a covered benefit. The 
Plan denied your request. The Plan says that refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. The Plan also says this service 
(refraction) is only covered when a routine eye examination is performed. The Plan also says that the eye exam 
performed on the date of service in question was not a routine eye exam. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for refraction services by a contract provider. The file does not show that the Plan provided 
valid notice that refraction services would not be covered. The Plans EOC is not valid notice of non-coverage 
because there is language that says one routine eye examination, including refraction, is covered every year. 
The financial liability form the contracted provided supplied to the enrollee is not valid notice of non-coverage 
because it is non-specific and doesnt clearly state that refraction services would be non-covered. Under 
Medicare rules, this means the refraction services are considered approved by the Plan. Therefore, we decided 
that the Plan has to pay for an eye refraction (92015) provided on August 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
iVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee was hospitalized in 
October with a COPD exacerbation, and ABG while acutely ill showed mild hypercapnia. The enrollee is 
severely obese.  There are no pulmonary function tests to assess the severity of the COPD at baseline. There is 
no ABG done while stable to document chronic CO2 retention. There is no consideration of OSA. If the 
enrollee does have chronic CO2 retention, may benefit from BiPAP with AVAPS during sleep. Medicare does 
not cover a home ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vascular services (procedure code 36012, 37252, 37253, 
75822, 75825) provided to the enrollee on August 18, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 denied codes is: 
 
CPT 36012: 
 
Selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein, 
petrosal sinus) 
 
CPT 37252: 
 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to 
code for primary procedure) 
 
CPT 37253: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; each additional noncoronary vessel (List separately in 
addition to code for primary procedure 
 
CPT 75822: 
 
Venography, extremity, bilateral, radiological supervision and interpretation 
 
CPT 75825: 
 
Venography, caval, inferior, with serialography, radiological supervision and interpretation 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the record contains a list of 
procedures but does not actually describe them being performed. There is no vascular access or movement of 
catheters into the vessels included in the note. The documentation does not support that these procedures were 
performed. 
 
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 vascular services (procedure code 36012, 37252, 37253, 75822, 75825) provided to the enrollee 
on August 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
1, 2022, to May 5, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG and principal diagnosis code were 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 DRG 689. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee was admitted to the hospital with altered mental status and he was started on antibiotics 
empirically during the workup. Urinary tract infection (UTI) was suspected; however, urine culture was 
negative, and antibiotics were stopped. Therefore, the diagnosis of UTI was not sufficiently supported in the 
provided documentation for this admission. Therefore, the DRG of 689 is also not supported.  
 
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 to the enrollee from May 1, 2022, to May 5, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the chest x-ray interpretation provided on September 28, 2022, billed 
with code 71045-26-77. 
 
You asked the Plan to pay for the x-ray interpretation. You say that multiple exams were performed on this 
date, so the denied claim is not a duplicate. The Plan denied your request. The Plan says that this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The records submitted support that the rendering 
physician performed the x-ray interpretation twice on the date of service at issue. Based on this information, we 
decided that Medicare rules for coverage of the x-ray interpretation have been met. Therefore, we decided that 
the Plan has to pay for the chest x-ray interpretation provided on September 28, 2022, billed with code 71045-
26-77.  
 
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 repeat treatment with Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. You say that the requested treatment is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the number of treatments with hyaluronic acid injections 
is limited to two total treatments in a lifetime. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat injections for shoulder arthritis are limited 
to a single repeat course. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Synvisc have not been met. Specifically, the case record indicates that the request is for a repeat 
course of injections into the shoulders. The available medical records document that the enrollee has already 
been provided with a repeat course of injections. Therefore, we decided that the Plan does not have to pre-
approve repeat treatment with Synvisc (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine 
reevaluation and management (99397) provided on June 15, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that this service should be 
covered. The Plan denied your request. The Plan says this service is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the Physician Fee Schedule Status Indicator N 
means that this is a non-covered service. There will be no payment amounts for these codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the evaluation and management service have not been met. Therefore, we decided that the Plan 
does not have to pay for the periodic comprehensive preventive medicine reevaluation and management 
(99397) provided on June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex device. You say that you disagree with the denial. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare. 
 
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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertilfex device is experimental and investigational. There is more research 
needed due to insufficient evidence of efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an insertion of interlaminar/interspinous process stabilization/distraction device, 
without open decompression or fusion, including image guidance when performed, lumbar; single level 
(22869, 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute-care hospital where the enrollee is currently receiving care. The Plan has approved ongoing care in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 services related to end-stage renal disease (ESRD) provided on August 
2, 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 21, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. 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 for the HCPCS/CPT code will be denied. 
 
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. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
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 21, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on from October 26, 2022 to 
November 9, 2022 by an out-of-network provider. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 
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 psychotherapy provided on from October 26, 2022 to  
November 9, 2022 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 22, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service October 22, 
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 24, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. 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 for the HCPCS/CPT code will be denied. 
 
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. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
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 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary and the 
enrollee's best option for care. The Plan denied your request. The Plan says based on Medicare guidelines, the 
IRF services you are requesting do 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.