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

 
We decided that the Plan does not have to pay for the laboratory services coded as 81286, 81413, 81414, 
81442, 81161, 81479 provided January 25, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the Lab does not require active 
medical/State license and your lab is operating within Texas. The Plan denied your request. The Plan says this 
provider was not certified/eligible to be paid for this procedure/service on this date of service.  
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 the laboratory services coded as 
81286, 81413, 81414, 81442, 81161, 81479 provided January 25, 2022. have been met. The Plan made 
multiple attempts to obtain supporting medical records from the provider without success.. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded as 81286, 81413, 81414, 81442, 
81161, 81479 provided January 25, 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 it is felt that IRF care is needed. The Plan denied 
your request. The Plan says criteria for IRF care are not met. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for confusion and respiratory failure and was transferred to skilled nursing on  8/12/22 then transferred to long term care on 9/4/22. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. 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 this patient 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says therapy can be done at home. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no skilled nursing needs, such as parenteral agents, wounds, or tubes. 
You are functioning at a home care level. You do not require daily skilled services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 49560) provided to the enrollee on 
April 18, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied code is inclusive to another billed code. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found that the 
enrollee underwent repair of enterocutaneous fistula with existing ventral hernia. This required a small bowel 
resection and anastomosis - CPT code 44120. At the end of the procedure, the hernia defect was also repaired 
utilizing mesh. The records do support that CPT 49650 was performed as a secondary or separate procedure, as 
it was present and required repair distinct from just closure of the fascia. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 49560) provided to the enrollee on April 18, 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: 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 patient would benefit from IRF care. The Plan 
denied your request. The Plan says criteria for IRF care are not met. 
 
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 patient was admitted for confusion, stroke, and seizure. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. 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 
this patient 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve of implantation of the Aurora Spine ZIP Interspinous 
Fixation device (22612). 
 
You asked the Plan to pre-approve the Aurora Spine ZIP Interspinous Fixation device. You say that it is your 
position that the denial for this procedure is unwarranted and unsupported by the enrollee's current medical 
status and is inconsistent with currently accepted medical practice. The Plan denied your request. The Plan says 
the interspinous-interlaminar fusion surgery and the devices used for it remain experimental for use. More 
research is needed to show safety and efficacy of the procedure and the devices. 
 
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 the Aurora Spine ZIP Interspinous 
Fixation device. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found interspinous devices remain experimental. More 
research is needed to show safety and efficacy. 
 
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 Aurora Spine ZIP Interspinous Fixation device have not been met. Therefore, we decided that the Plan does not have to pre-approve of implantation of the Aurora Spine ZIP 
Interspinous Fixation device (22612).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 billed for date of service April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on March 23, 
2021. 
 
You asked the Plan to pay for the hospital care. You say that your records indicate the claim was filed timely. 
The Plan denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the hospital care was not filed until May 5, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the subsequent hospital care (99232) provided on March 23, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided to the enrollee on March 10, 2022. 
 
You asked the Plan to pay for the services. You say that these services were medically necessary and were 
performed by a credentialed provider. The Plan denied your request. The Plan says that codes 81210 and 81235 
are not supported in the medical records provided, and codes 88346 and 88350 would be better reported with a 
more accurate code for the circulating tumor cell portion of this test. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee had cerebrospinal fluid 
sent to pathology, and then had fluid sent for molecular profiling/genetic analysis, including BRAF. This 
coding was appropriate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
laboratory services provided to the enrollee on March 10, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (procedure code 87150) provided to the enrollee on 
May 11, 2021. 
 
You asked the Plan to pay for the services. You say that these services were necessary and are supported in the 
medical records. The Plan denied your request. The Plan says that 12 units of 87150 are not supported in the 
records provided. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found that the 
medical documentation supports the use of procedure code 87150 with 12 units. There is an edit between codes 
87150 and 87500; however, the documentation does support the use of modifier -59 in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
laboratory services (procedure code 87150) provided to the enrollee on May 11, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services (procedure code 64445) provided to the 
enrollee on March 1, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 64445 remains not supported, as the medical 
records indicate that a genicular nerve block. 
 
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 64445 is "Injection(s), anesthetic agent(s) and/or steroid; 
sciatic nerve." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical documentation does 
not support the use of CPT 64445. There is a more appropriate procedure code that captures the nerves blocked 
as procedure code 64454 that captures Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services (procedure code 64445) provided to the enrollee on March 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were residing in the skilled nursing facility at a custodial level of care when they 
were diagnosed with COVID-19 infection. You were treated supportively for symptoms associated with 
COVID-19. You did not require any skilled nursing or rehabilitation services on a daily basis at an inpatient 
level of care. You remained medically stable and did not require any further skilled nursing or rehabilitation 
services. You were noted to be at or near your functional and medical baseline. You did not have any parental 
medication, complex wound care or nutrition given via a feeding tube. Continued care at the skilled level was 
not medically necessary after the last covered day 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiological examination of the chest (71046) provided on 
February 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a radiological examination of the chest. You say that the referring provider 
should have requested authorization. The Plan denied your request. The Plan says services were provided by an 
out-of-network provider and there was no prior authorization on file. 
 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 radiological examination of the chest (71046) 
provided on February 16, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 15, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the records show that the patient had two 
separate trips on this date. The Plan denied your request. The Plan says the cost of these ambulance services is 
included in the payment to the hospital. 
 
 
 
 
 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that if an ambulance is used for the transportation of 
a hospital inpatient to another facility for diagnostic tests or special treatment, the ambulance trip is considered 
part of the diagnosis-related group (DRG) and not separately billable.  In this case, the records show that the 
patient was an inpatient in the hospital.  They were transported to another facility for specialized treatment and 
then returned to the inpatient hospital.  According to Medicare rules, such transports are included in the 
payment made to the hospital and are not separately billable. Therefore, we decided that the Plan does not have 
to pay for ambulance services provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 24, 2020. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Medicare 
denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year 
from the date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for physician's services was not filed until March 11, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on December 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81286, 81413, 81414, 
81442, 81161 and 81479 provided November 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the Lab does not require active 
medical/State license and your lab is operating within Texas. The Plan denied your request. The Plan says this 
provider was not certified/eligible to be paid for this procedure/service on this date of service. 
 
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 the laboratory services coded as 
81286, 81413, 81414, 81442, 81161 and 81479 provided November 10, 2021 have been met. The Plan made 
multiple attempts to obtain supporting medical records from the provider without success. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded as 81286, 81413, 81414, 81442, 
81161 and 81479 provided November 10, 2021.