Persius/hicric huggingface dataset:
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 appears to be somewhat unstable and requires additional short term acute 
care services that can be safely administered at the current facility until more stable and appropriate for a lower 
level of care. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 the subsequent hospital care services coded 99231 provided 
on February 28, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. 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. 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 99231 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem 
focused interval history; A problem focused examination; Medical decision making that is straightforward or of 
low complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
 We find that CPT code 99231 is not supported in the medical record. Specifically, this code was billed during 
the global surgical period of code 44050 (Reduction of volvulus, intussusception, internal hernia, by 
laparotomy) and is included in the payment for the surgical procedure performed by the same provider. The 
documentation shows that an appropriate modifier was not billed on the claim to represent that this code was 
unrelated to the 90-day post operative period of the major procedure provided on February 23, 2022. Based on 
this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not 
been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services 
coded 99231 provided on February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test, definitive, 22 or more classes (G0483) 
provided November 23, 2021. 
 
You asked the Plan to pay for the drug test, definitive, 22 or more classes. You say that the drug test was 
medically necessary. The Plan denied your request. The Plan says that the condition of the enrollee did not 
meet the Medicare rules for approval of definitive urine drug testing (UDT) for 22 or more drug classes. 
 
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 the drug test, definitive, 22 or more classes. 
Our reviewer says that the drug test, definitive, 22 or more classes is not medically reasonable and necessary. 
Our physician reviewer found that the condition of the enrollee does not meet the Medicare rules for approval 
of definitive urine drug testing (UDT) for 22 or more drug classes (G0483). The diagnosis is medication 
management of long term (current) drug therapy. The medical record sent by the provider shows presumptive 
screening test results which are partially inconsistent with prescription medications, or history and expected 
results. Definitive confirmation testing was medically necessary for only 1 drug class: Tricyclic 
Antidepressants. The review has determined that the items/services at issue in this case are not medically 
reasonable or 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 the drug test, definitive, 22 or more classes have not been met. Therefore, we 
decided that the Plan does not have to pay for the drug test, definitive, 22 or more classes (G0483) provided 
November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 and 87640 billed for date of service 
November 12, 2021. 
 You asked the Plan to pay for procedure code 87481 and 87640. You say that you disagree with the denial. The 
Plan denied your request. The Plan says payment for codes 87481 and 87640 is bundled into payment for code 
87801. 
 
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 
87481 and 87640 are column II codes to column I code 87801. 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 87481 and 87640 billed for 
date of service November 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service February 23, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams. The Plan 
denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service February 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electronic analysis of an implanted 
neurostimulator provided on March 30, 2022. 
 
You asked the Plan to waive the copayment for the neurostimulator analysis. You say that you have not been 
charged previously for diagnostic testing. 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 $100 
copayment for diagnostic procedures and tests. Your contract with the Plan also says that enrollees must pay a 
$40 copayment for office visits with a specialist.  
You have been asked to pay a $100 copayment for an office visit with a specialist and diagnostic procedures 
and tests. The record shows you have already paid $40 on the date of service leaving you a balance of $100. 
The neurostimulator analysis falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. The office visit falls within the Physician/Practitioner Services, Including Doctors 
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 the electronic analysis of 
an implanted neurostimulator provided on March 30, 2022.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided you only requires short term additional acute 
care services that can safely be administered at the current 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: 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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 appears to be somewhat unstable and requires additional short term acute 
care services that can be safely administered at the current facility until more stable and appropriate for a lower 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen supply services provided on January 10, 2022. 
 
You asked the Plan to pay for the services provided. You say that the claim should be paid as billed. The Plan 
denied your request. The Plan says no further payment will be made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. W 
 
We find that 36 rental payments were provided from July 2018, to September 2021. There is no further 
payment for oxygen equipment during the 5-year reasonable useful lifetime (RUL) of the equipment after 36 
rental payments have been made.  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 the oxygen supply services provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram provided on May 14, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
Independent Physician Association (IPA) is responsible for claims processing. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
 
 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the claim to the primary payer. As the secondary insurer, the Plan cannot be held responsible 
for the services provided until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the electroencephalogram provided on May 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomic testing services provided on 
September 16, 2021. 
 
You asked the Plan to pay for the testing services. You say that the billed charges are appropriate for the level 
of services provided. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 the panel testing was not submitted with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the pharmacogenomic testing services provided on September 16, 2021.
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 February 24, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this fee is in addition to the primary 
anesthesia procedure and is separately payable based on guidelines. You say that the description of services 
documents the qualifying circumstances that enable this code to be paid. 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 February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace rendered on March 21, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 back brace rendered on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 81455 
provided on December 17, 2021. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under CPT 
code 81455 are not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the code at issue is 81455. This code is 
specifically not covered. Based on this information, we decided that Medicare rules for coverage of the targeted 
genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay 
for the targeted genomic sequence analysis panel coded 81455 provided on December 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology genetic testing coded 81542 provided on March 
25, 2022. 
 
You asked the Plan to pay for the oncology genetic testing. 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 an appropriate DEX-Z code identifier should be 
entered adjacent to the CPT code in the comment/narrative field. 
 
We looked at the file and Medicare rules. Review of the file does not support that a DEX-Z code identifier was 
entered adjacent to the CPT code in the comment/narrative field. Based on this information, we decided that 
Medicare rules for coverage of the oncology genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the oncology genetic testing coded 81542 provided on March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetic testing panel provided on October 22, 
2021. 
 
You asked the Plan to pay for the testing services. You say that the records support the billed charges. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 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 the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the pharmacogenetic testing panel provided on October 22, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for a molecular pathology procedure (81479) provided on January 20, 
2022. 
 
You asked the Plan to pay for molecular pathology services. You say that you have provided medical records to 
support the services at issue. The Plan denied your request. The Plan says that rules for payment have not been 
met because only one unit of the requested service can be billed. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the case record does not document that any other unit of procedure 
code 81479 was billed for the same date of service. It is the Plan's responsibility to substantiate its denial. In 
this case, the denial has not been substantiated, so we must find in your favor. Therefore, we decided that the 
Plan has to pay for a molecular pathology procedure (81479) provided on January 20, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction you received on June 23, 2021. 
 
You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover eye refractions. 
 
We looked at the file and the Plan's rules. The Plan covers only routine eye exams and eyglasses/contact lenses. 
Eye refractions are not covered by the Plan or Medicare. Based on this information, we decided that the Plan's 
rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay 
for the eye refraction you received on June 23, 2021.