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

 
We decided that the Plan does not have to pay for genetic testing provided on December 14, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 genetic testing provided on December 14, 2021, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on August 20, 2021. 
 
You asked the Plan to pay for physical therapy services. You say that the medical records required to reprocess 
the denied claim are attached. The Plan denied your request. The Plan says the code is not appropriate for the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as 
services incident to a physician/ NPP service, because they do not meet the qualifications of a therapist. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Immunohistochemistry (IHC) stain test provided on May 
5, 2022, by an OON provider. 
 
You asked the Plan to pay for an Immunohistochemistry (IHC) stain test. You say that you are appealing the 
denial of the service provided. The Plan denied your request. The Plan says the out-of-network services were 
not authorized. 
 
 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 Immunohistochemistry (IHC) stain test 
provided on May 5, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on February 7, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for wound care services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 wound care services provided on February 7, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CPAP and tubing with heating element provided on April 
25, 2022, by an OON provider. 
 
You asked the Plan to pay for a continuous positive airway pressure device, and tubing with heating element. 
You say that you have used a CPAP for years and purchased a new one. You say that you do not understand 
why it would be denied and should be covered.  The Plan denied your request. The Plan says the services were 
rendered by a non-participating provider with Medicare. 
 
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 CPAP and tubing with heating element provided 
on April 25, 2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 that the requested admission to an IRF 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 found to be medically reasonable and necessary. Our physician reviewer found the 
clinical documentation shows that you have multiple active comorbidities and hospital complications and 
would require close medical supervision on an inpatient basis. The evaluating therapists state that you require 
intense therapy and multiple disciplines (physical therapy, occupational therapy) thus IRF criteria has been met 
and is medically necessary.  
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial mastectomy procedure (19301) billed for date of 
service November 13, 2021. 
 
You asked the Plan to pay for a partial mastectomy. You say that you have provided medical records to support 
the services billed. 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 a partial mastectomy have not been met. 
Therefore, we decided that the Plan does not have to pay for a partial mastectomy procedure (19301) billed for 
date of service November 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828), an addition, endoskeletal, knee-shin system, stance flexion 
feature, adjustable (L5845), an addition to endoskeletal knee-shin system, fluid stance extension, dampening 
feature (L5848) and an addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor 
control feature, swing and stance phase, includes electronic sensor(s) (L5856). 
 
You asked the Plan to pre-approve prosthetics. You say that the devices are medically necessary. The Plan 
denied your request. The Plan says there is no compelling clinical justification for the requested microprocessor 
K3 functional level KNEE system. The requested prosthetic components exceed your needs. 
 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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that you require a Blatchford Orion 3 microprocessor knee. 
The requested knee has features that exceed your medical need such as a cycling mode and intuitive 
programming software. The treating medical provider/physician documentation does not support that your 
functional needs cannot be met adequately with a mechanical K3 knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control (L5828), an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), an 
addition to endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848) and an addition 
to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance 
phase, includes electronic sensor(s) (L5856).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on March 9, 2022. 
 
You asked the Plan to pay for code 83789. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on March 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 27425 and 27435 billed for date of service 
February 16, 2022. 
 
You asked the Plan to pay for procedure codes 27425 and 27435. You say that you disagree with the denial. 
The Plan denied your request. The Plan says payment for code 27425 and 27435 is bundled into payment for 
codes 27447. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
27425 and 27435 are column II codes to column I code 27447. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 27425 and 27435 billed for 
date of service February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry services represented by code 83789-59 
and billed for date of service March 16, 2022. 
 
You asked the Plan to pay for code 83789-59. You say that the lab-test yielded inconsistent results. You say 
that the enrollee was diagnosed with several conditions and prescribed several high-dependency narcotic 
medications. You say that some drugs may or may not be present in the enrollee's urine drug sample. You say 
that it is vitally necessary to test not only for the drug but for metabolites also known as biomarkers that are 
often present in the sample well after the drug is no longer present in the sample. You say that urine drug 
testing is necessary to monitor the use of these prescriptions as part of the Prescription Drug Monitoring 
Programme. The Plan denied your request. The Plan says the service which remains in dispute is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that providers performing 
validity testing on urine specimens used for drug testing shall not separately bill the validity testing. Medicare 
rules also say that procedures must be ordered by the physician who is treating the beneficiary and using the 
results in the management of the beneficiary's specific medical problem. 
 
We find that CPT code 83789-59 is not supported in the medical record. Specifically, code 83789-59 is not 
separately reimbursed because it was billed for specimen validity testing on urine specimens utilized for drug 
testing. In addition, the records do not demonstrate that the procedure in dispute was ordered by the physician 
who is treating the beneficiary in order to use the results in the management of the enrollees specific medical 
problem. Rather, your argument for coverage explains that the testing which remains in dispute was used to 
confirm that a urine specimen was unadulterated. Based on this information, we decided that Medicare rules for 
coverage of code 83789-59 have not been met. Therefore, we decided that the Plan does not have to pay for 
mass spectrometry services represented by code 83789-59 and billed for date of service March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81408, 81407, 81439, and 81286) 
provided on July 27, 2021. 
 
You asked the Plan to pay for codes 81408, 81407, 81439, and 81286. You say that you would like the Plan to 
reconsider their denial of payment. 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 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 (81408, 81407, 81439, and 81286) provided on July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation and one dental extraction by an oral 
surgeon. 
 
You asked the Plan to pre-approve an evaluation and one dental extraction by an oral surgeon. You say that the 
services are necessary. The Plan denied your request. The Plan says covered dental services must be provided 
by a participating general dentist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
evaluation and one dental extraction by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve dental services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the dental services requested are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service March 17, 
2022. 
 
You asked the Plan to pay for procedure code 20930. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 20930 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 20930 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service October 30, 
2021. 
 
You asked the Plan to pay for procedure code 99053. You say that each charge was for a separate medically 
necessary visit. The Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99053 billed for date of service October 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service December 9, 
2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed service 
cannot be verified. 
 
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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 We find that CPT code 99497 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99497 billed for date of service December 9, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services provided from April 29, 2022, 
to May 3, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that code 
99497 is included in code 99223. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. For, CPT code 99497, the complete medical record submitted was not 
included in the case file. The record that was included, shows that it was page 1 of 5, but no other pages were 
included. The file does not show that the Plan received incomplete medical records, especially since the Plan 
approved code 99223 for April 29, 2022. For code 99223 provided from May 1, 2022, to May 3, 2022, the Plan 
states the codes were not appealable. However, the Plan did not provide a valid reason why a decision for these 
services were not rendered. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the evaluation and management services provided from April 29, 2022, to May 3, 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.