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

 
We decided that the Plan does not have to pay for lab services provided on March 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 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 March 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary.  The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you are currently undergoing treatment at an ACH for sepsis and renal failure due to 
lower extremity cellulitis. You are not intubated/ventilated. There is no evidence that you require services that 
are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute 
services are required. You can then be transferred/discharged to a lower level of care for any ongoing LTC 
needs. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed on November 14, 2021, and 
December 29, 2021. 
 
You asked the Plan to pay for procedure code 99072. You say that the medical records fully support and justify 
billing code 99072. You say that the daily notes clearly show what kind of precautions taken and the claim 
should be reprocessed for payment. The Plan denied your request. The Plan says procedure code 99212 was 
paid and procedure code 99072 remains denied as bundled services are not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
  We find that CPT code 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99072 billed on November 14, 2021, and December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on March 18, 2022 
by an out-of-network (OON) provider. 
 
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 were rendered by an out-of-network provider without 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 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 the outpatient hospital services provided on March 
18, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for epidurography services provided to the enrollee on October 
28, 2021. 
 
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 code 72275 is "Epidurography, 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 use of CPT 72275 for 
fluoroscopic documentation of appropriate location of epidural steroid injection is not an appropriate code. This 
code is reserved for diagnostic epidurography, with detailed description of nerve roots, etc - not the 
documentation of epidural injection. CPT 62323 would have been more appropriate. 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 epidurography services provided to the enrollee on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on March 
21, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you did not spend that much time 
with the doctor. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for each specialist visit.  
 
 
 
 
 
 
 You have been asked to pay a $25 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a MyoPro Motion G orthotic device. 
 
You asked the Plan to pre-approve MyoPro Motion G. You say that this device is appropriate. The Plan denied 
your request. The Plan says the denial of authorization for this item is correct, because this device has deluxe 
features that exceed your needs, and it replaces - rather than improves - the function of your arm. 
 
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 MyoPro Motion G. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current clinical guidelines designate robotic therapy to be of uncertain utility 
compared to dose-matched conventional upper limb exercise therapies and has unproven benefit in the home 
environment for patients with your condition. In addition, the records report left upper extremity spasticity 
which may be a contraindication for use of this device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G have not been met. Therefore, we decided that the Plan does 
not have to pre-approve use of a MyoPro Motion G orthotic device.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 70450 billed for date of service June 23, 2021. 
 
You asked the Plan to pay for code 70450. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says that payment for 70450 is bundled into the payment for 
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. However, the record shows that 70496 was performed by a 
provider with a primary taxonomy of 2085R0202X (Radiology Diagnostic Radiology) while 70450 was 
performed by a provider with a primary taxonomy of 2085B0100X (Radiology Body Imaging). Although these 
services were performed at the same facility, they were not performed by providers with the same primary 
specialty; therefore, the NCCI edit does not apply in this case. Based on this information, we decided that 
Medicare rules for coverage of code 70450 have been met. Therefore, we decided that the Plan has to pay for 
procedure code 70450 billed for date of service June 23, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that criteria for an MRI is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
an MRI is not medically reasonable and necessary. While this patient reports left leg weakness her neurological 
exam showed normal lower extremity reflexes. There is no report of lumbar spine x-ray in this patient who has 
been seen for scoliosis. There is a standing order for physical therapy and the patient has not yet undertaken the 
program. There is no red flag documented in the records and there is no contraindication to pursuing the 
physical therapy program as prescribed prior to proceeding to MRI. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an MRI for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services (71045, 70450) provided on November 
25, 2021. 
 
You asked the Plan to pay for imaging services. You say that this claim should be paid. The Plan denied your 
request. The Plan says 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. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 5, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for imaging services have not been met. 
Therefore, we decided that the Plan does not have to pay for the imaging services (71045, 70450) provided on 
November 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 22, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on January 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingles vaccine received on December 6, 2021. 
 
You asked the Plan to pay for the Shingles vaccine. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine received on 
December 6, 2021.  
 
Benefits for the Shingles vaccine 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee was admitted with a headache and found to have acute infarct in left 
posterior inferior cerebellar artery distribution involving left cerebellum and medulla as well as an inferior 
posterior fossa lesion compatible with meningioma. The record indicates that the enrollee still requires acute 
care services. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that he is not currently receiving but that 
would be available at the LTACH facility. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on August 24, 
2021, to October 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the treatment received by the 
member was medically necessary. You also say that the physician provided a statement of medical necessity. 
The Plan denied your request. The Plan says the services performed by the non-participating provider from 
August 24, 2021, to October 19, 2021, were not authorized by the Plan, and were not referred by a participating 
provider. 
 
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 a domiciliary or rest home visit provided on 
August 24, 2021, to October 19, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, G0483) provided March 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that the 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 
 
 
 
 
 We find that CPT codes 80307, & G0483 are not supported in the medical record. Specifically, the provided 
lab requisition from the physician does not specify which tests were ordered. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (80307, G0483) provided March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 24, 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 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, a cardiovascular risk assessment panel, 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 rendered on April 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on January 10, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that it is the provider's fault that you had to 
have this x-ray, so the copayment should be waived. The Plan denied your request. The Plan says the 
copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for basic imaging services.  
 
You have been asked to pay the allowed amount of $25.87, which is less than the $35 copayment for an x-ray. 
An x-ray falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an x-ray provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service December 2, 
2021. 
  You asked the Plan to pay for procedure code 93010. You say that a provider who prepares a separately 
identifiable interpretation which contributes to the diagnosis and treatment of the patient is entitled to payment. 
You say that the claim was improperly denied and should be reprocessed in accordance with CPT or CMS 
guidelines. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment for 
code 92960. 
 
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 93010 
is a column II code to column I code 92960. 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 93010 billed for date of service December 2, 
2021.