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

 
We decided that the Plan does not have to pay for subsequent nursing facility care (procedure code 99309) 
provided to the enrollee on August 2, 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 the procedure code billed is not appropriate for the associated place of service - assisted living 
facility. 
 
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 99309 is "Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using total time on the date of the encounter for code 
selection, 30 minutes must be met or exceeded." 
 
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 record show that the services were performed in an assisted living facility. A different code is required for this situation. 
 
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 subsequent nursing facility care (procedure code 99309) provided to the enrollee on August 2, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the finger(s) provided on September 23, 
2021. 
 
You asked the Plan to pay for the x-ray exam of the finger(s). You say that you disagree with the Plan's denial. 
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 November 10, 2021. 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 the x-ray exam of the finger(s) have not been 
met. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the finger(s) provided on 
September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mechanical traction therapy (97012), therapeutic exercises 
(97110), and therapeutic activities (97530) provided by a chiropractor on April 8, 2022, to April 25, 2022. 
 
You asked the Plan to pay for mechanical traction therapy, therapeutic exercises, and therapeutic activities. 
You say that these services should be covered. The Plan denied your request. The Plan says these services are 
not supported in the records. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for mechanical traction therapy (97012), therapeutic exercises (97110), and 
therapeutic activities (97530) provided by a chiropractor on April 8, 2022, to April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on July 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported in the 
medical record. 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 (81479) provided on July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care discharge services billed with code 
99217 for January 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a physician may not bill the hospital observation 
discharge management code (code 99217) or an outpatient/office visit for the care provided while the patient 
received hospital outpatient observation services on the date of admission to inpatient status.  
 
We looked at the file and Medicare rules. The file shows that billed procedure code 99217 was not billed with 
initial or subsequent hospital care codes. Therefore, we decided that the Plan does not have to pay for the 
observation care discharge services billed with code 99217 for January 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services (procedure code 88305) provided 
to the enrollee on September 15, 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 this is the incorrect procedure code. 
 
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 not supported by the medical records. Our reviewer found that the laboratory report describes prostate needle biopsy/cystoscopy. Current Medicare coding regulation require that surgical pathology, 
including gross and microscopic examination, from a single patient be reported with one unit of service of 
Healthcare Common Procedure Coding System (HCPCS) G0416, rather than CPT 88305. In this case, the 
incorrect code was reported. 
 
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 surgical pathology services (procedure code 88305) provided to the enrollee on September 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endoscopic retrograde cholangiopancreatography (ERCP); 
with biopsy, single or multiple provided to the enrollee on July 7, 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 the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 43261 is "Endoscopic retrograde 
cholangiopancreatography (ERCP); with biopsy, single or multiple." 
 
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 procedure report describes 
stent placement and biopsy in the same surgical field, and in this case would not be reported separately. The 
documentation does not support the use of modifier -59. CPT 43261 would be included in CPT 43274. 
 
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 endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple 
provided to the enrollee on July 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 119 units of procedure code 11046 provided to the enrollee 
on May 4, 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 due to the absence of the required medical documentation, this 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 11046 is "Debridement, muscle and/or fascia (includes 
epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List 
separately in addition to code for primary procedure)." 
 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 records do not include 
sufficient documentation to support the code or the number of units billed. 
 
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 119 units of procedure code 11046 provided to the enrollee on May 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial inpatient hospital care provided on July 8, 2022, 
billed with code 99223. 
 
You asked the Plan to pay for the inpatient hospital physician visit. You say that the records for July 8, 2022, 
were submitted to support this is a separate service. The Plan denied your request. The Plan says this was not 
billed with the correct Place of Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
  
We find that CPT code 99223 is for inpatient physician services. However, the Plan has shown that the enrollee 
was in outpatient observation on the date of service. There is a more appropriate code for this service. Based on 
this information, we decided that Medicare rules for coverage of the inpatient hospital physician visit have not 
been met. Therefore, we decided that the Plan does not have to pay for the initial inpatient hospital care 
provided on July 8, 2022, billed with code 99223.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the dialysis services provided April 1, 2022, to April 29, 2022. 
 
You asked the Plan to pay for the dialysis services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the information submitted is insufficient for processing. 
 
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. The Plan states that the information submitted is insufficient for processing. The 
documentation does not include what information is insufficient or Medicare rules to support this denial. The 
Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the dialysis services 
provided April 1, 2022, to April 29, 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: Unfavorable

 
We decided that the Plan does not have to pre-approve Cologuard cancer screening (81528). 
 
You asked the Plan to pre-approve Cologuard cancer screening. You say that this service is necessary and was 
ordered by the enrollee's treating physician. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for coverage of a Cologuard test. 
 
The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered when all the 
necessary criteria are met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Cologuard cancer screening have not been met. Specifically, the enrollee is not between 50 and 85 years of age. Therefore, we decided that the Plan does not have to pre-approve Cologuard cancer screening 
(81528).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device. 
 
You asked the Plan to pre-approve the high frequency chest wall oscillation device. You say that this service 
was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillation device.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoCycle FES Home Cycling System (E1399). 
 
You asked the Plan to pre-approve a MyoCycle FES Home Cycling System. You say that the following 
sections provide information supporting that the MyoCycle is medically necessary DME for the enrollee. The 
Plan denied your request. The Plan says exercise equipment is not covered because it is not primarily medical 
in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a MyoCycle FES Home Cycling System (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic scale. 
 
You asked the Plan to pre-approve an electronic scale. You say that you are strictly required to control your 
daily diet. According to your doctor's instructions, you are asking for an electronic scale from the Plan to 
monitor your diet. The Plan denied your request. The Plan says this item is not covered, and the enrollee does 
not meet the Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an electronic scale have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve an electronic scale.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TAADNext genetic testing. 
 
You asked the Plan to pre-approve TAADNext genetic testing. You say that TAADNext genetic testing is 
medically necessary. The Plan denied your request. The Plan says the requested TAADNext genetic testing 
does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 TAADNext genetic testing. Our 
reviewer says that TAADNext genetic testing is not medically necessary. Our physician reviewer found that 
you had surgical repair of aortic dissection in 2003 and recent stable computed tomography imaging. The test is 
described as a comprehensive analysis of 35 genes associated with TAAD and related disorders. It is not a 
diagnostic test. There is no evidence to support its role in your clinical management. In summary, the requested 
testing is not considered reasonable or 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 TAADNext genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve TAADNext genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper left quadrant periodontal scaling and root planing 
- four or more teeth per quadrant (D4341 x1). 
 
You asked the Plan to pre-approve the upper left quadrant periodontal scaling and root planing - four or more 
teeth per quadrant (D4341 x1). You say that you are requesting a reconsideration as you have been diagnosed 
with periodontal disease. The Plan denied your request. The Plan says this service is not medically necessary. 
 
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. The Plan covers the upper left 
quadrant periodontal scaling and root planing - four or more teeth per quadrant (D4341) when the services are 
medically necessary and reasonable.  
 
 
 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 upper left quadrant periodontal 
scaling and root planing - four or more teeth per quadrant (D4341 x1). Our reviewer says that the service is not 
medically necessary. Our physician reviewer found the documentation indicated that the periodointal charting 
of the upper left quadrant did not reveal pathologic pocketing (greater than 4mm). Due to the poor quality of 
the radiographs, a determination of bone loss or subgingival calculus accumulation could not be made. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the upper left quadrant periodontal scaling and root planing - four or more teeth 
per quadrant have not been met. Therefore, we decided that the Plan does not have to pre-approve upper left 
quadrant periodontal scaling and root planing - four or more teeth per quadrant (D4341 x1).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for the F2 (G20210A variant) and F5 
genes (coagulation factor V) (81240 and 81241). 
 
You asked the Plan to pre-approve genetic testing. You say that these tests are medically reasonable and 
necessary. The Plan denied your request. The Plan says testing for these genes is only covered for pregnant 
patients. The enrollee is not pregnant; therefore, this testing is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the Factor V Leiden (FVL) variant in 
the F5 gene and the G20210G>A (G20210A) variant in the F2 gene is only covered and medically necessary in 
pregnant patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the records provided do not indicate that the 
enrollee is pregnant. Therefore, we decided that the Plan does not have to pre-approve genetic testing for the F2 
(G20210A variant) and F5 genes (coagulation factor V) (81240 and 81241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement upper-extremity prosthesis (L6100, 
L6680, L6706 L7400, L7403). 
 
You asked the Plan to pre-approve a replacement upper-extremity prosthesis. You say that the items at issue 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for 
durable medical equipment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the 
reasonable useful lifetime of equipment can in no case be less than 5 years. Computation of the useful lifetime 
is based on when the equipment is delivered to the enrollee, not the age of the equipment. 
 
We looked at the file and Medicare rules. In this case, you are requesting a replacement for an upper-extremity 
prosthesis approved for the enrollee on December 13, 2021. Therefore, the requested replacement is for an item 
that has not outlasted its reasonable useful lifetime. Based on this information, we decided that Medicare rules 
for coverage of a replacement upper-extremity prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement upper-extremity prosthesis (L6100, L6680, L6706 L7400, 
L7403).