Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral health services (90834) provided on November 7, 
2022. 
 
You asked the Plan to pay for the behavioral health services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the behavioral health services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. The appeal letter states that an attempt to contact the physician was made, however this is 
not documented in the provided medical records along with date, time, or method of notification. Therefore, we 
decided that the Plan does not have to pay for behavioral health services (90834) provided on November 7, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (90999) provided from March 1, 2022, to March 
20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not 
recognized under OPPS. 
 
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 payment for CPT code 90999 is not supported in the medical record. Specifically, code 90999 is 
assigned a status indicator of B under the outpatient prospective payment system (OPPS), which means that 
this code is not recognized under OPPS, and therefore is not payable. 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 the services (90999) provided from March 1, 2022, to March 20, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the wheelchair provided to you on June 24, 2022. 
 
You asked the Plan to pay for the wheelchair. The Plan denied your request. The Plan says that services from a 
non-participating provider is not covered under your plan unless they are authorized before the services are 
provided. 
 
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 argues that the wheelchair is not covered because it was not authorized. 
However, you have a PPO plan. This means that authorization is not required for out-of-network services, as 
explained in the Plan's Evidence of Coverage. The Plan has not provided documentation to substantiate its 
denial. Therefore, we decided that the Plan has to pay for the wheelchair provided to you on June 24, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography and a short-latency somatosensory 
evoked potential (SSEP) study provided to the enrollee on May 16, 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 the denied codes is: 
 
CPT 95870: 
 
Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or 
bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters 
 
CPT 95938: 
 
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 
recording from the central nervous system; in upper and lower limbs 
 
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 in terms of CPT 95938, the 
documentation includes two provider remittance advices. The procedure report describes SSEP in upper and 
lower limbs (ulnar and posterior tibia); therefore, one unit is supported. The additional unit cannot be verified. 
 
Additionally, we have confirmed that CPT 95861 is a column II code to column I code CPT 95861. 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. 
 
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 needle electromyography and a short-latency somatosensory evoked potential (SSEP) study 
provided to the enrollee on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided July 27, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
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. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided July 
27, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code J3490 billed for date of service October 27, 2022. 
 
You asked the Plan to pay for the billed services. You say that the drug was used as part of the enrollee's 
treatment. The Plan denied your request. The Plan says that the code is included in the global surgery period of 
a minor procedure. 
 
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 J3490 is unclassified drugs. We find that CPT code J3490 
is supported in the medical record. The national drug code and medical records confirm that the enrollee 
received a Bupivacaine Hydrochloride injection. While visits by the same physician on the same day as a minor 
surgery are included in the payment for the procedure, code J3490 is not considered one of these packaged 
visits. Based on this information, we decided that Medicare rules for coverage have been met. Therefore, we 
decided that the Plan has to pay for procedure code J3490 billed for date of service October 27, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on September 8, 
2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the order was not 
dated. 
 
The Plan must follow Medicare rules. Medicare rules say that the order/prescription must have an order date.  
 
We looked at the file and Medicare rules. The order/prescription for the electrical stimulator/supplies in this 
case did not have an order date as required by Medicare rule. Based on this information, we decided that 
Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for the electrical stimulator supplies provided on September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87631) provided on July 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 87631 is "Infectious agent detection by nucleic acid 
(DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, 
parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets". 
 
We find that CPT code 87631 is not supported in the medical record. Specifically, the records do not show that 
3-5 targets were tested on the date of service in question. 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 the lab services (87631) provided on July 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care (procedure code 99305) provided 
to the enrollee on July 19, 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 code remains denied, as there is a more appropriate code to describe the services provided. 
 
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 99305 is "Initial 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, 35 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 medical records do not 
support the use of the procedure code 99305, as the National Provider Identifier (NPI) is not listed as a skilled nursing facility. 
 
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 initial nursing facility care (procedure code 99305) provided to the enrollee on July 19, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the cerebral perfusion analysis billed with code 0042T for September 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 that the diagnosis code is not supported. 
 
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 billed diagnosis codes are not supported for code 0042T 
per Local Coverage Article (LCA) A56902. This LCA is not valid for Part B Medicare for the state of 
Colorado and is not binding. The Plan has not provided any documentation or binding Medicare rules to 
support that code 0042T is not payable as billed. Therefore, we decided that the Plan has to pay for the cerebral 
perfusion analysis billed with code 0042T for September 8, 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 pay for validity testing billed with code 83789 and presumptive drug 
testing billed with code 80307 for date(s) of service July 7, 2022. 
 
You asked the Plan to pay for codes 83789 and 80307. You say that these services are medically necessary and 
should be paid. The Plan denied your request. The Plan says code 83789 is not separately payable. Code 80307 
is not supported by the medical records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. The rules also say that that 
providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, we find that the testing described by code 83789 is 
not separately payable. In addition, code 80307 is used to report drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; includes sample validation when performed. No results of any 
presumptive drug tests were included in the medical records provided. Therefore, this service cannot be 
verified. Therefore, we decided that the Plan does not have to pay for validity testing billed with code 83789 
and presumptive drug testing billed with code 80307 for date(s) of service July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM) device (K0553) provided September 29, 2021. 
 
You asked the Plan to pay for the CGM supply allowance. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the services are not 
documented in the enrollee's medical records. 
 
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 physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Specifically, the submitted medical records did 
not include exam notes from the referring physician to support that an exam was done within 6 months prior to 
the prescribing of the items. There was no documentation that matched the date of service on the claim 
submitted by the provider for this enrollee, nor proof of delivery documentation matching the shipping or 
delivery date. 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 supply allowance for 
therapeutic continuous glucose monitor (CGM) device (K0553) provided September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network endocrinologist. 
 
You asked the Plan to pre-approve these services. You say that the enrollee would like a second opinion. The 
Plan denied your request. The Plan says the services are available from network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network endocrinologist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service July 6, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that these services 
were necessary and were reported correctly. 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 the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. 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) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (procedure code K0553) 
provided to the enrollee on October 19, 2022. 
 
You asked the Plan to pay for the monitor.. You say that payment should be reconsidered. The Plan denied 
your request. The Plan says the date of service October 19, 2022, does not match the delivery/shipping date or 
the date the label was created. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that procedure code K0553 is not supported in the medical record. Specifically, the date of service is 
listed as October 19, 2022, on the claim. The item was delivered on October 13, 2022, and the item was shipped on October 11, 2022. Based on this information, we decided that Medicare rules for coverage of the 
monitor. have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose 
monitor (procedure code K0553) provided to the enrollee on October 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary due to the 
enrollee's decrease in function after open heart surgery. The Plan denied your request. The Plan says the IRF 
services requested 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 
for February 24, 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 99285 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that Current Procedural Terminology (CPT) modifier -25 
should only be used on claims for evaluation and management (E/M) services, and only when these services 
are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the 
same day as another procedure or other service. 
 
We looked at the file and Medicare rules. The file shows that code 99285 was not billed with the required -25 
modifier. 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 emergency room (ER) services 
billed with code 99285 for February 24, 2022.