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

 
We decided that the Plan does not have to pay for procedure code 76857 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code 76857. You say that you do not believe this code should be 
bundled. The Plan denied your request. The Plan says payment for code 76857 is bundled into payment for 
code 76856. 
 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 76857 
is a column II code to column I code 76856. 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 76857 billed for date of service March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 13, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided documentation to support 
payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have 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 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were admitted for pneumonia, confusion, and renal insufficiency. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 72100-26, 73560-26-RT, and 73560-26-LT billed for 
date of service June 6, 2022. 
 
You asked the Plan to pay for codes 72100-26, 73560-26-RT, and 73560-26-LT. You say that the patient had 
multiple exams on this date of service. 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 July 14, 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 codes 72100-26, 73560-26-RT, and 73560-26-LT have not been met. Therefore, we decided that the Plan does not have to pay for codes 72100-26, 73560-26-RT, 
and 73560-26-LT billed for date of service June 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (code 76700-59) and the 
retroperitoneal ultrasound (code 76770) billed for date of service February 22, 2022. 
 
You asked the Plan to pay for codes 76700-59 and 76770. You say that these services were medically 
necessary for this patient. The Plan denied your request. The Plan says the documentation submitted does not 
support these services. 
 
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 codes 76700-59 and 76770 have been 
met. Specifically, we looked at the medical records you submitted for this date of service. The only imaging 
services that are noted in the records are arterial doppler duplex ultrasounds of the right and left lower 
extremities.  There is no documentation of an abdominal or retroperitoneal ultrasound. Therefore, we decided 
that the Plan does not have to pay for the abdominal ultrasound (code 76700-59) and the retroperitoneal 
ultrasound (code 76770) 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 adult sized disposable incontinence product (T4521). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the denial and would 
like the plan to reconsider payment. The Plan denied your request. The Plan says the requested item is not 
covered by original Medicare and therefore not covered by the plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve adult sized disposable 
incontinence product (T4521).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical boot (L3260) provided on June 29, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthopedic footwear) are only covered for 
patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthopedic footwear may be appropriate for you, neither Medicare nor the Plan provides coverage of this item 
for your condition. Additionally, with the exception of situations described, orthopedic footwear billed using 
code L3260 will be denied as non-covered. Therefore, we decided that the Plan does not have to pay for the 
surgical boot (L3260) provided on June 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have the services a dual-energy X-ray absorptiometry (DXA), bone density 
study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) provided to the enrollee on June 14, 2022. 
 You asked the Plan the services the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation does not include information that the patient received the screening 
study for one of the covered risk categories. 
 
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 the services the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the dictated history of "screening" per the report does not satisfy the criteria. While it would be 
assumed the patient is post-menopausal and thus qualify for this screening exam as her initial study the post-
menopausal state is not specified in the report history; thus, the criteria is not satisfied for reimbursement. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have the services a dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial 
skeleton (eg, hips, pelvis, spine) provided to the enrollee on June 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on February 20, 2022. 
 
You asked the Plan to pay for the x-ray. You say that the service should be covered. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 11, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray 
(71045) provided on February 20, 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. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements. 
 
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.  
 The enrollee was admitted for non-surgical management of pelvic fractures and humerus fracture after a fall. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cryo knee brace (codes A9901 and L1833-NU-LT-KX) 
billed for date of service October 22, 2021. 
 
You asked the Plan to pay for the cryo knee brace. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you did not provide adequate proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery of these items.  Specifically, the shipping information you 
provided does not include a packing slip or receipt that details the specific items dispensed and shipped. Therefore, we decided that the Plan does not have to pay for the cryo knee brace (codes A9901 and L1833-NU-
LT-KX) billed for date of service October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care (99220) provided on September 2, 2021. 
 
You asked the Plan to pay for the observation care. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99220 is not supported in the medical record. Specifically, the code was billed with the 
GT modifier. This modifier is for telehealth services and is not a valid modifier for observation care. Based on 
this information, we decided that Medicare rules for coverage of the observation care have not been met. 
Therefore, we decided that the Plan does not have to pay for observation care (99220) provided on September 
2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on August 9, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that this provider is the only therapist in your area that 
accepts Medicare. The Plan denied your request. The Plan says Plan members must use network providers, 
except in emergency or urgent situations, or for out-of-area kidney dialysis services. When specialized services 
are not available from network providers, we will review and provide prior authorization for getting those 
services from out-of- network providers. 
 
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 August 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says IRF care is not medically necessary. 
 
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 you are medically stable and do 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. You do not need 3 hours a day for 5 days a week of 
therapies with multidisciplinary approach in an IRF. Your rehabilitation needs can be safely met in a lower 
intensity setting. The documentation does not support the medical necessity for admission to an IRF due to lack 
of medical complexity, and nursing needs. While you would benefit from physical therapy and occupational 
therapy, your needs can be safely provided in an alternate and low intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service May 22, 
2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
May 22, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 23, 2022. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says it is not responsible for this claim because the member 
was on hospice on this date of service.  The Plan says that it has recouped payment for these services for this 
reason. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on February 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (EKG) testing rendered on May 29, 
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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 93005 has an OPPS status indicator of Q1(S), 
which has a packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator 
"S, "T, or "V." The file shows that code 93005 was billed with code 99285, which has an OPPS status 
indicator of V. Payment for code 93005 is packaged into payment for 99285. Therefore, we decided that the 
Plan does not have to pay for the electrocardiogram (EKG) testing rendered on May 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 29, 2022 billed with 
code 87801. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
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. While this is the only code at issue in this appeal, previous codes 
have already been paid for this same date of service. This means that this was part of 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 June 29, 2022 billed with code 87801.