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

 
We decided that the Plan does not have to pay for procedure code 76937 billed for date of service April 22, 
2022. 
 You asked the Plan to pay for procedure code 76937. You say that the service was medically necessary. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 76937. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 76937. Based on this information, 
we decided that Medicare rules for coverage of procedure code 76937 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76937 billed for date of service April 22, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76641 billed for date of service August 16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records support the procedure performed. 
The Plan denied your request. The Plan says that the code has an MUE value of 1. 
 
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 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. 
 
We find that CPT code 76641 was billed with 1 unit of service with modifier RT on one claim line, and 1 unit 
of service and modifier LT on the second claim line. We also find that code 76641 has an MUE of 2, not 1. 
Based on this information, we decided that Medicare rules for coverage of the billed services have been met. 
Therefore, we decided that the Plan has to pay for procedure code 76641 billed for date of service August 16, 
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: Favorable

 
We decided that the Plan has to pay for procedure code 99223 billed for date of service August 10, 2022. 
 
You asked the Plan to pay for the billed services. You say that your physician advised you to go to the 
emergency room. The Plan denied your request. The Plan says that the service was billed with an inappropriate 
place of service. 
 
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 supported. The records show that you were admitted to inpatient care on the 
same day you received observation services. Medicare payment for the initial hospital visit includes all services 
provided to the patient on the date of admission by that physician, regardless of the site of service. 
Furthermore, you received the services at issue at an in-network facility. Based on this information, we decided 
that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99223 billed for date of service August 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second emergency department visit provided to the enrollee 
on June 12, 2022. 
 You asked the Plan to pay for the services. You say that the enrollee was seen twice on the same date of service 
at two different times and/or by two different providers. The Plan denied your request. The Plan says the 
documentation received does not indicate that the two emergency department visits billed on the date of service 
were performed for unrelated issues. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 record includes 
documentation of two emergency department visits on the same date of service, by two different providers, 
same specialty. Both visits were for "scrotal pain." In this case, both visits would be combined and the correct 
evaluation and management code would be 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 a second emergency department visit provided to the enrollee on June 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's functional status has been significantly 
impaired. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an 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 that there are no complex nursing or rehabilitation needs. While the enrollee may 
need 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 
the enrollee 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing provided on May 19, 2022. 
 
You asked the Plan to pay for the FoundationOne CDx testing. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the FoundationOne 
CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne CDx testing provided on May 19, 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 skilled nursing rehab has failed the enrollee twice, 
the enrollee needs IRF services so he may be able to live independently. The Plan denied your request. The 
Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are needed for you to 
regain full mobility. The Plan denied your request. The Plan says the request 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 that you do not require services at the LTACH that are not available at the acute care 
hospital where you currently receiving care. All medically necessary care is being provided in the current acute 
care setting. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision care services provided from January 14, 2022, to 
January 17, 2022, by an out-of-network provider. 
 You asked the Plan to pay for the vision care services. You say that you were informed that no referrals were 
needed. The Plan denied your request. The Plan says services from non-participating providers are not covered 
unless they are authorized before the services are provided. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 vision care services. Our reviewer says 
that the records do not indicate that the care provided was medically necessary. Our physician reviewer found 
the enrollee's symptoms were not deemed emergent nor vision threatening. 
 
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 vision care services have not been met. Therefore, we decided that the Plan 
does not have to pay for vision care services provided from January 14, 2022, to January 17, 2022, by an out-
of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 2 power wheelchair and wheelchair 
accessories K0842, E1012, E2311, E2377, E2313, E2361, E1007, E1028, E0955, and E2603. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that please approve the 
repositioning power wheelchair. The Plan denied your request. The Plan says the request for the group 2 
multiple power option K0842 power wheelchair does not meet medical necessity criteria. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has chronic knee and back pain and has a history of near 
falls. The enrollee does not have neurological deficits and does not have an antalgic gait. The request per the 
physician, is for a scooter to get the enrollee out of the house. There is no evidence enrollee is unable to do 
MADLs in the home. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Group 2 power wheelchair and wheelchair accessories K0842, 
E1012, E2311, E2377, E2313, E2361, E1007, E1028, E0955, and E2603.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and the 
pneumatic appliance (E0673) provided on April 27, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says this item cannot be billed separately from the surgical 
center. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. In addition, this item is not separately payable from the 
surgical procedure. Therefore, we decided that the Plan does not have to pay for the pneumatic compression 
device (E0675) and the pneumatic appliance (E0673) provided on April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein 
(code 36475) and sclerotherapy of telangiectasia and incompetent veins (code 36465). 
 
You asked the Plan to pre-approve endovenous ablation therapy of incompetent vein and sclerotherapy of 
telangiectasia and incompetent veins. You say that endovenous ablation therapy of incompetent vein and 
sclerotherapy of telangiectasia and incompetent veins is medically necessary. The Plan denied your request. 
The Plan says endovenous ablation therapy of incompetent vein and sclerotherapy of telangiectasia and 
incompetent veins does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that  
 
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 endovenous ablation therapy of incompetent vein and sclerotherapy of telangiectasia and incompetent veins. Our reviewer says that the 
requested endovenous ablation therapy of incompetent vein and sclerotherapy of telangiectasia and 
incompetent veins is not medically necessary. Our physician reviewer found that the documentation does not 
meet coverage criteria and does not support the medical necessity the procedures in question. There is 
unsatisfactory documentation that the enrollee is having lifestyle limiting symptoms due to his varicose veins, 
only noting some discomfort with prolonged standing. The enrollee has a history of peripheral vascular disease; 
however, no pulse examination or assessment of arterial perfusion is performed. It is not possible to attribute 
the enrollees leg symptoms to varicose veins without an assessment of arterial perfusion. Additionally, the 
progress note narrative does not discuss the elements of the enrollees pain that require chronic opioid use. This 
information would be helpful in assessing whether a particular procedure would be expected to improve the 
enrollees mobility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy of incompetent vein and sclerotherapy of 
telangiectasia and incompetent veins have not been met. Therefore, we decided that the Plan does not have to 
pre-approve endovenous ablation therapy of incompetent vein (code 36475) and sclerotherapy of telangiectasia 
and incompetent veins (code 36465).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided June 2, 2022, to July 1, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that certain data elements are required on the claim and NOA. 
Any claim with incomplete, missing, or invalid information for all of these elements may be returned as 
unprocessable.  
 
Review of the file shows that an appropriate NOA claim was submitted for period of care; however, the final 
home health claim does not have a matching admission date of January 03, 2022. As the NOA has invalid 
information, no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay 
for the home health services provided June 2, 2022, to July 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that in order to sustain a safe and sustainable 
discharge, LTACH is the best option for the enrollee's care. The Plan denied your request. The Plan says 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial for admission to an IRF. 
The Plan denied your request. The Plan says that the coverage criteria has not been 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 that you do not have 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. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 24, 2022, billed with 
multiple codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 24, 2022, billed with multiple codes.