Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 23, 2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was seen in the immediate care 
location. The Plan denied your request. The Plan says the amount indicated is over the Plan allowable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99213 was reprocessed and paid for by the Plan. A bill for assigned services is 
considered paid in full when the Medicare allowed amount is paid. Therefore, we decided that the Plan does 
not have to further pay for the office visit provided on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic panel testing provided on January 15, 2021. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting documentation. 
The Plan denied your request. The Plan says the denial of payment for this testing is correct, because a panel 
constitutes a single procedural service so one procedure code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single procedure code shall be reported for the procedure.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for genetic panel testing provided on January 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met.  
  
Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 
services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet joint injections (64636) provided on November 15, 
2021. 
 
You asked the Plan to pay for the facet joint injections (64636). You say that the notes state there were three 
levels done for this procedure and payment for CPT code 64636 should be processed. The Plan denied your 
request. The Plan says procedure code 64636 is not supported by the medical records submitted. 
 
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 64636 is destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint 
(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 facet joint injections (64636). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the procedure report documents radiofrequency ablation of medical branch nerves on the left and right side. A 
bilateral facet nerve intervention is still considered a single level intervention. In, this case additional facet 
joints are not supported. 
 
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 facet joint injections (64636) have not been met. Therefore, we decided that 
the Plan does not have to pay for the facet joint injections (64636) provided on November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (L0650), and ankle brace (L1971), provide 
don April 28, 2021. 
 
You asked the Plan to pay for the back and ankle brace. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, and therefore, the billed supply code cannot be 
verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. The medical records submitted do not indicate a need for the 
ordered items and there is no packing slip to identify the items shipped. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the back brace (L0650), and ankle brace (L1971), provide don April 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 Antigen test (87426) provided on February 3, 
2022. 
 
You asked the Plan to pay for the COVID-19 Antigen test. You say that the cruise line required the COVID-19 
test for boarding. You also say that you spoke to someone from the Plan, and they stated that as long as the test 
was done by an approved pharmacy it would be covered. The Plan denied your request. The Plan says the 
testing performed was not ordered by a physician or medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare.  
 
 We looked at the file and Medicare rules. This testing was required by a cruise line for the purposes of routine 
travel. Based on this information, we decided that Medicare rules for coverage of screening testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 Antigen test (87426) 
provided on February 3, 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 you need physical therapy and occupational therapy 
for recovery so you can meet your baseline. The Plan denied your request. The Plan says based on Medicare 
guidelines, the requested SNF services do not meet the requirements for approval. 
 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 daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound rendered on February 8, 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 separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93975. 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 the abdominal ultrasound rendered on February 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on January 8, 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 separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, 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 the computed tomography (CT) scan of the head/brain rendered 
on January 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 3, 2021. 
 
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 testing is not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that the item is medically necessary. The Plan 
denied your request. The Plan says Medicare doesn't cover wheelchair without an evaluation by your doctor 
that shows which type of wheelchair is most suitable to address your medical need. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 a power wheelchair. have been met. 
Specifically, there is no medical records or indication as to what type of wheelchair is being requested or what 
would be best for your needs.. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0988) 
provided on December 30, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you fell out of your bed. You say that you 
were not able to stand without assistance. The Plan denied your request. The Plan says since there was no 
transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 30, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0988) provided on December 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen 
rendered on November 15, 2021. 
 
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 separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74177 
is a column II code to column I code 74174. 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 the computed tomography (CT) scan of the abdomen rendered on 
November 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on February 10, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on February 10, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the non-emergency ambulance 
transportation (A0428) provided on September 28, 2021. 
 
You asked the Plan to waive the copayment for the non-emergency ambulance transportation. You say that 
your daughter was told there would be no copayment for the transport, otherwise you would have used another 
transportation service. You also say that you were assured there would be no cost share involved. The Plan 
denied your request. The Plan says as the allowed amount of $237.25 is less than the copayment of $250, your 
liability of $237.25 applied as the copayment. The Plan also says that the copayment amount you are being 
charged is correct. 
 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each one-way Medicare covered ground trip for Ambulance Services.  
 
You have been asked to pay a $250 copayment for the non-emergency ambulance transportation. the non-
emergency ambulance transportation falls within the Ambulance Services benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the non-emergency ambulance transportation (A0428) provided on 
September 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable pulse generator. 
 
You asked the Plan to pre-approve an implantable pulse generator. You say that this is medically necessary. 
The Plan denied your request. The Plan says the requested service is considered experimental/investigational. 
 
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 pulse generator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the requested device is still the subject of medical studies meaning that 
it is too early to know if it is helpful and safe. Since it is not known if the device is helpful and safe it is 
considered not medically necessary and reasonable. The device is considered investigational. The review has 
determined that the items/services at issue in this case are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable pulse generator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an implantable pulse generator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) stay from 
December 27, 2021, through December 31, 2022. 
 
You asked the Plan to waive the copayment for SNF. You say that your stay was less than 20 days, and you are 
allowed 20 days without charge. You say that you do not understand why the insurance did not cover your stay. 
The Plan denied your request. The Plan says coinsurance is correct. 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 
copayment per days 1-20 and an $184 copayment per days 21-100 for skilled nursing facility. A new benefit 
period will begin on day one when you first enroll in a Medicare Advantage plan, or when you have been 
discharged from skilled care in a skilled nursing facility for 60 consecutive days. 
 
You have been asked to pay $920 for days 21-25 ($184/day x 5/days = ($920). SNF falls within the Skilled 
nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for skilled 
nursing facility (SNF) stay from December 27, 2021, through December 31, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on December 23, 
2021. 
 
You asked the Plan to pay for the emergency room services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the emergency department visit is not supported in the medical record. Specifically, the revenue 
code 636 has been billed on one line without a necessary accompanying code per the guidelines. The revenue 
code 636 is not eligible for an Outpatient Code Editor (OCE) 48 edit Bypass. The submitted claim did not meet 
Medicare OCE billing guidelines with regards that line. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does 
not have to pay for the emergency room services provided on December 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services provided from November 
25, 2021, to December 31, 2021. 
 
You asked the Plan to pay for the services provided. You say that your health is changing for the good from the 
pump and medication. The Plan denied your request. The Plan says the services are not valid for Medicare 
purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9328 is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, 
these services.  Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services provided 
from November 25, 2021, to December 31, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy service provided on April 20, 2021. 
 
You asked the Plan to pay for outpatient therapy. You say that payment for this service is past due. The Plan 
denied your request. The Plan says payment is not allowed for this revenue code when it is billed without the 
requested corresponding CPT code. A corrected claim may be submitted to the Plan directly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The service at issue was not billed with an appropriate CPT code; only a revenue code was provided. Based on 
this information, we decided that Medicare rules for coverage of outpatient therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for the outpatient therapy service provided on April 
20, 2021.