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

 
We decided that the Plan does not have to pay for the laboratory services provided from September 1, 2021, to 
September 3, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 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 provided from 
September 1, 2021, to September 3, 2021, have been met. No medical records were provided for review after multiple attempts to obtain the records were made by the Plan. Therefore, we decided that the Plan does not 
have to pay for the laboratory services provided from September 1, 2021, to September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing rendered on January 14, 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 procedure code G0483 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. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records show that only 
two drug classes were tested. 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 definitive drug 
testing rendered on January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on November 19, 2021. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this testing was billed with incorrect coding. 
 
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.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the record does not show that this testing was separate and distinct from the other test 
codes billed separately. Based on this information, we decided that Medicare rules for coverage of services 
billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for 
genetic testing provided on November 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that you are appealing with supporting records. 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 lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting a reconsideration of authorization 
approval for inpatient rehabilitation services with documentation to support medical necessity. The Plan denied 
your request. The Plan says coverage for the inpatient rehabilitation facility level of care does not meet the 
definition of medical necessity. The enrollee's needed care can be provided at a lower level such as skilled 
nursing facility. 
 
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 enrollee was admitted for respiratory failure and congestive heart failure. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the RF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services (15100-AS-82, 15120-AS-
82, 15004-AS-82, 15002-AS-82, and 97605-AS-82) provided on March 29, 2021. 
 
You asked the Plan to pay for codes 15100-AS-82, 15120-AS-82, 15004-AS-82, 15002-AS-82, and 97605-AS-
82. 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 follows Medicare rules. The rules say that procedures billed with the assistant-at-surgery physician 
modifiers -80, -81, -82, or the AS modifier for physician assistants, nurse practitioners and clinical nurse 
specialists, are subject to the assistant-at-surgery policy. Modifiers -80, -81 or -82 should not be billed with 
modifier AS on the same claim, by the same provider or on the same date of service. Therefore, we decided 
that the Plan does not have to pay for the assistant at surgery services (15100-AS-82, 15120-AS-82, 15004-AS-
82, 15002-AS-82, and 97605-AS-82) provided on March 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service December 9, 
2021. 
 You asked the Plan to pay for procedure code 76942. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 76942 is bundled into 
payment for code 32555. 
 
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 76942 
is a column II code to column I code 32555. 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 76942 billed for date of service December 9, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided on January 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that the enrollee cannot choose which radiologist reads their 
diagnostic tests. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the x-
ray. We found no exception that would require the Plan to pay for the x-ray. The records provided for review 
do not show that the x-ray was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the x-ray provided on January 11, 2022, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept, intraosseous ablation of the basivertebral 
nerve, procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's pain is disabling. The 
Plan denied your request. The Plan says experimental procedures are not covered by Medicare. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for spondylosis without myelopathy/radiculopathy of the 
lumbar region. He presented with chronic low back pain. He denies radicular symptoms. The exam reveals 
decreased active and passive range of motion of the lumbar spine secondary to pain, and discomfort at extreme 
ranges of motion. There is tenderness to palpation throughout the lumbar spine L1 through S1. Overall, 
documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. 
Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time.  There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested Intracept intraosseous ablation of the basivertebral 
nerve at L2-S1, in this case, is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept, intraosseous ablation of the basivertebral nerve, procedure.
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 you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services 
you are requesting do not meet the requirements for approval. 
 
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 document does not support the medical necessity for admission to 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that this device is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage for the 
requested device have not been met. 
 
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 an implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at issue is the appropriateness and medical necessity of implanting an ILR 
in the clinical management of your condition. You have no history of atrial fibrillation, nor were any significant 
cardiac arrhythmias noted on ECG monitoring. A recent randomized clinical trial found that continuous 
monitoring for atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial 
fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of 
an ILR would not be considered medically appropriate and necessary in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the insertion of an implantable loop recorder.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service March 17, 
2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 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 the office visit and injection services provided on December 
29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and injection services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
  
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 did not pre-approve the 
office visit and injection services. We found no exception that would require the Plan to pay for the office visit 
and injection services. The records provided for review do not show that the services at issue were urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for the office visit and injection services 
provided on December 29, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that this procedure is medically reasonable and 
necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because there is a lack of randomized, blinded clinical studies examining the long-term clinical outcomes 
establishing the value of CardioMEMS. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes to establish the value of CardioMEMS in patient management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided from January 16, 2022, to 
January 17, 2022. 
 
You asked the Plan to pay for the hospital services. You say that the services should be paid. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Though the 
enrollee ended Medicare Hospice benefits on January 16, 2022, the services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital services 
provided from January 16, 2022, to January 17, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus testing provided on November 29, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the coronavirus testing provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dispensing fee (V5160), hearing aid (V5261), and 
hearing aid or assistive listening device/supplies/accessories (V5267) provided on November 15, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the dispensing fee, hearing aid, and hearing aid or assistive listening 
device/supplies/accessories. You say that you were originally told to go to this provider. You also say that the 
provider was told that the Plan would pay up to $2,500 for each hearing aid device. The Plan denied your 
request. The Plan says hearing aids must be purchased through the Plan's hearing aid vendor to be covered 
under the hearing aid services offered by the Plan. The Plan also says that you did not contact the customer 
service department to confirm your hearing aid benefits prior to receiving these services on November 15, 
2021. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor to use your hearing aid benefits.  
 
 We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the dispensing fee, hearing aid, and hearing aid or assistive listening device/supplies/accessories 
have not been met. Therefore, we decided that the Plan does not have to pay for the dispensing fee (V5160), 
hearing aid (V5261), and hearing aid or assistive listening device/supplies/accessories (V5267) provided on 
November 15, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90832) provided on March 
1, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for THE outpatient mental health services. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
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 outpatient mental health services (90832) provided 
on March 1, 2022 by an out-of-network (OON) provider.