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

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
June 22, 2021, through June 30, 2021, billed with code ODKC1. 
 You asked the Plan to pay for the SNF services as billed. You say that the MDS form is filled out correctly 
which resulted in the correct HIPPS code being billed. The Plan denied your request. The Plan says the HIPPS 
code reported on this claim is not supported. Code PDQD1 shoudl have been billed. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for SNF services is based on a HIPPS 
code with five case-mix groups which are assigned based on the information from the MDS assessment. The 
rules say that for reporting functional abilities in Section GG, facilities must assess self-care performance based 
on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or 
family documented in the residents medical record during the three-day assessment period.  
 
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 SNF services as billed. Our reviewer 
says that the documentation does not support the documented findings in the MDS assessment form. Our 
physician reviewer found the clinical documentation in the case file for the dates in question is insufficient to 
support the billing of morbid obesity due to excess calories for the enrollee in this case. The documentation is 
also insufficient to support the reported functional scores for the PT/OT and nursing sections. 
 
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 SNF services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) services provided from June 22, 2021, through 
June 30, 2021, billed with code ODKC1.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Nodify CDT test (81599) provided June 16, 2022. 
 
You asked the Plan to pay for the Nodify CDT test. You say that this test is clinically useful. The Plan denied 
your request. The Plan says this test is considered investigative/experimental, therefore not covered. 
 
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 pay for Nodify CDT test. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that it appears that plasma-based proteomic tests may be helpful for assessing risk of cancer in 
patients that have pulmonary nodules, but there is not enough research to show that these tests can improve 
health outcomes for these patients. In addition, clinical guidelines based on research do not recommend this 
testing. Therefore, proteomic screening, including, but not limited to Nodifiy XL2TM, Nodify CDTTM, BDX-
XL2, Xpresys Lung and Xpresys Lung 2, is considered investigational for the evaluation of pulmonary 
nodules. There is not enough research to show that gene expression tests can improve health outcomes for 
patients with pulmonary nodules. In addition, clinical guidelines based on research do not recommend this 
testing. Therefore, gene expression profiling, including but not limited to Percepta Bronchial Genomic 
Classifier, is considered investigational for the evaluation of pulmonary nodules. 
 
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 Nodify CDT test have not been met. Therefore, we decided that the Plan 
does not have to pay for the Nodify CDT test (81599) provided June 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87634, 87632, and 87503 billed for date of 
service January 21, 2022. 
 
You asked the Plan to pay for procedure codes 87634, 87632, and 87503. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for code 87634 is bundled into payment for 
code 87632. The Plan also says that codes 87632 and 87503 are not covered. 
 
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 87634 
is a column II code to column I code 87632. This claim has not been billed with an appropriate modifier to 
bypass the edit. Code 87632 is specifically not a covered benefit. Code 87503 is an add-on code and has not 
been billed with an appropriate primary procedure code since code 87632 is not covered. 
 
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 87634, 87632, and 87503 billed for date of service January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9279, S1015, and S8301 billed for date of 
service July 7, 2022. 
 
You asked the Plan to pay for procedure codes A9279, S1015, and S8301. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the billed codes are invalid for Medicare 
purposes. 
 
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 codes A9279, S1015, and S8301 have a Status Indicator of I on the Physician Fee Schedule. This means that procedure codes A9279, S1015, and S8301 are not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of procedure codes A9279, S1015, and 
S8301 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A9279, 
S1015, and S8301 billed for date of service July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye appointment provided on July 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an eye appointment. You say that this is medically necessary and should be 
covered. The Plan denied your request. The Plan says there was no preauthorization by a primary care provider 
(this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 an eye appointment provided on July 28, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87481, 87556, 87561 and 87563) provided 
on August 26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the facility should be responsible for these charges. 
The Plan denied your request. The Plan says these services are not covered because they were provided OON. 
 
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 lab services (87481, 87556, 87561 and 87563) 
provided on August 26, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit, an x-ray 
examination of the pelvis, and an x-ray examination of the knee provided on July 22, 2022. We also decided 
that the Plan does not have to waive the coinsurance for a triamcinolone acetonide injection also provided on 
July 22, 2022. 
 
You asked the Plan to reduce the copayment for a specialist office visit, a triamcinolone acetonide injection, an 
x-ray examination of the pelvis, and an x-ray examination of the knee. You also asked the Plan to waive the 
coinsurance for a triamcinolone acetonide injection. You say that you thought the $45 copayment would cover 
everything. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
  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 20% 
coinsurance for Medicare Part B drugs, a $30 copayment for each basic imaging service, and a $45 copayment 
for each in-person specialist visit. 
 
You have been asked to pay $2.06 in coinsurance, which is 20% of the allowed amount for a triamcinolone 
acetonide injection (10.32 x 20% = $2.06). A triamcinolone acetonide injection falls within the Medicare Part 
B drugs benefit category. You have also been asked to pay a $30 copayment for an x-ray examination of the 
pelvis, and an x-ray examination of the knee. An x-ray examination of the pelvis, and an x-ray examination of 
the knee falls within the basic imaging services benefit category. You have also been asked to pay a $45 
copayment for a specialist office visit. A specialist office visit falls within the in-person specialist visit 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 reduce the copayment for a specialist office visit, an x-ray examination 
of the pelvis, and an x-ray examination of the knee provided on July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on May 23, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went to the urgent care 
on May 23, 2022, for an x-ray. You also ay you left with no care having been received. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
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 $30 
copayment for urgent care center. 
 
You have been asked to pay a $30 copayment for an urgent care visit. This item/service falls within the urgent 
care center 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 urgent care visit 
provided on May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 24, 2022, through 
May 2, 2022. 
 
You asked the Plan to pay for these services. You say that the acute inpatient hospital care provided was 
medically necessary for the enrollee. The Plan denied your request. The Plan says that the acute inpatient 
hospital care provided was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the review indicates that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department (ED) and/or observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from April 24, 2022, through May 2, 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 waive the coinsurance for the knee/shin prosthesis (L5910), test 
socket below the knee (L5620), preparatory prosthesis (L5540), below the knee total contact (L5637), socket 
insert (L5679), prosthetic socks (L8420, L8470), prosthetic shrinker below the knee (L8440), foot/ankle 
prosthesis (L5981), and the ankle prosthesis (L5968) provided on June 16, 2022. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 20% 
coinsurance for prosthetic devices and related supplies.  
 
 You have been asked to pay $1,660.02 (Plans allowed amount of $8,300.16 x 20% coinsurance) for the 
prosthetics items provided. 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 coinsurance for the knee/shin prosthesis 
(L5910), test socket below the knee (L5620), preparatory prosthesis (L5540), below the knee total contact 
(L5637), socket insert (L5679), prosthetic socks (L8420, L8470), prosthetic shrinker below the knee (L8440), 
foot/ankle prosthesis (L5981), and the ankle prosthesis (L5968) provided on June 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 88361, 88312, 88305 and 88112 provided on March 
31, 2022. 
 
You asked the Plan to pay for codes 88361, 88312, 88305 and 88112. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT codes 88361, 88312, 88305 and 88112 are not supported in the medical record. Specifically, 
these codes have a professional component/technical component indicator of 1. This claim was billed with a 
place of service 22 (on-campus outpatient hospital). the professional interpretation of a diagnostic test must be 
separately billed with modifier  26 by the interpreting physician. Based on this information, we decided that 
Medicare rules for coverage of codes 88361, 88312, 88305 and 88112 have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 88361, 88312, 88305 and 88112 provided on March 31, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 22, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says per Medicare, the 
provider must attempt to consult the attending or primary care physician about the services furnished and 
document the consent or declination date to consultations and the date of consultations in the patients medical 
record. If consultation with the attending or primary care physician is unsuccessful, document the patients 
medical chart with the date and manner of notification to the physician. There was no documented contact with 
the attending/primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99358 billed for date of service April 18, 
2022. 
 You asked the Plan to pay for procedure code 99358. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99358 is bundled into payment for code 90792. 
 
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 99358 
is a column II code to column I code 90792. 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 99358 billed for date of service April 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. 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 October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 18, 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 the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 pay for the laboratory services 
rendered on January 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee can safely receive the services they need in other settings, such as at home with supervision and home 
health services, or in an assisted living facility with home health services. 
 
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 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 IRF admission and services.