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

 
We decided that the Plan has to pay for colorectal cancer screening (procedure code G0105) provided to the 
enrollee on June 23, 2021. 
 
You asked the Plan to pay for the screening. You say that this should be paid for. The Plan denied your request. 
The Plan says that Healthcare Common Procedure Coding System (HCPCS) code G0105 (1 Unit) remains 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 G0105 is "Colorectal cancer screening; colonoscopy on individual at high risk." 
 
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 screening. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the medical records do indicate that 
colorectal cancer screening; colonoscopy on individual at high risk was performed. The enrollee had a previous 
history of an adenomatous colon polyp in 2019. The review has determined that the records support that G0105 
- colorectal cancer screening; colonoscopy on individual at high risk - was rendered in this case. The records 
substantiate this denied code. 
 
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 screening have been met. Therefore, we decided that the Plan has to pay for 
colorectal cancer screening (procedure code G0105) provided to the enrollee on June 23, 2021.  
 
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 the critical care (CPT code 99292) provided on August 4, 
2021. 
 
You asked the Plan to pay for the critical care. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service 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. 
 
CPT code 99292 remains not supported. This code represents an additional 30 minutes of critical care time in 
addition to the first 30-74 minutes of a critical care evaluation and management service (CPT code 99291). The 
submitted medical records document 40 minutes of critical care time. They do not support that an additional 30 
minutes of critical care services was performed in addition to the first 30-74 minutes of a critical care 
evaluation and management service (CPT code 99291) to support the billing of CPT code 99292. It is noted 
that multiple attempts were made to contact the provider for additional information. Based on this information, 
we decided that Medicare rules for coverage of the critical care have not been met. Therefore, we decided that 
the Plan does not have to pay for the critical care (CPT code 99292) provided on August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to provide an additional $150 reimbursement for the eyeglasses purchased on 
December 23, 2020. 
 
You asked the Plan to provide an additional $150 reimbursement for the eyeglasses. You say that you have not 
been reimbursed correctly. The Plan denied your request. The Plan says that the claims processed correctly as 
one of the pairs of glasses were billed by the provider with payment being sent directly to them. 
 
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 documentation available in the file is not sufficient to support that the Plan 
has made payment for both pairs of glasses provided on the date at issue. The Plan indicates that one was 
reimbursed to the enrollee and then another was paid to the provider, but we find no evidence to support this 
payment to the provider was included in the file. In addition, the Plan indicates that the provider wrote off 
charges beyond the $150, but this is also not supported as the enrollee has shown that a total of $665 was paid 
to the provider on this date. Based on the information in the file, it is not possible to determine whether the Plan 
has accurately paid these claims. As the enrollee clearly has paid more than $300 (the total allowed 
reimbursement for the two pairs), we find that the denial of the $150 being requested is not substantiated. 
Therefore, we decided that the Plan has to provide an additional $150 reimbursement for the eyeglasses 
purchased on December 23, 2020.  
 
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 the laboratory services (CPT code(s): 81206, 81301, 81311, 
81162, 81292, 81295, 81298, 81317, 81194, and 81309) provided on May 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 81162, 
81292, 81295, 81298, 81317, 81194, and 81309, remain not supported. The place of service on the CMS-1500 
form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim 
form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical 
documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11; 
therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional 
information from the provider. 
 
For CPT code(s):  81206, 81301, and 81311, if a laboratory assays two or more genes in a patient in parallel, 
then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural 
service, so one HCPCS code must be submitted for the panel. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (CPT code(s): 81206, 81301, 81311, 81162, 81292, 81295, 81298, 
81317, 81194, and 81309) provided on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on  
May 24, 2021. 
 
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 Current Procedural Terminology (CPT) code 81479 (1 Unit) remains not supported. 
 
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 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 laboratory services provided to the enrollee on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on September 2, 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 procedure code 12002 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 12002 (simple repair of superficial wounds) and 29125 
(application of short arm splint). Code 12002 is a column II code with a modifier indicator of 1 when billed 
with column I code 29125. Code 12002 was not billed with an appropriate modifier to allow for separate 
payment. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on 
September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 31, 
2020. 
 
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 Medicare denies coverage for all cardiovascular risk assessment testing genomic screening 
panels for suspected or documented cardiovascular disease. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review indicates that Medicare denies coverage for all cardiovascular risk assessment testing 
genomic screening panels for suspected or documented cardiovascular disease. Medicare only covers a lipid panel consisting of a total cholesterol, HDL cholesterol and triglycerides every 5 years as cardiovascular 
screening testing. The review has determined that the 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on October 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Domiciliary or rest home visit (99335) provided on 
November 10, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the Domiciliary or rest home visit provided by an OON provider. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-
network care. 
 
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 the Domiciliary or rest home visit (99335) 
provided on November 10, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that it is felt that this SNF care is needed. The 
Plan denied your request. The Plan says the requested services are not medically necessary at this time. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male who has 
suffered a subdural hematoma, currently being treated in an inpatient rehabilitation facility. From a nursing 
perspective, the beneficiary received oral medications and had stable vital signs. Regarding rehabilitation 
services, the beneficiary received physical, occupational, and speech therapy. The beneficiary was at a standby 
assist/supervision to contact guard assist level for functional mobility including gait to 100 feet. The 
beneficiary required varying assist with daily living activities. He tolerated a regular diet and thin liquids. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, the enrollee does not require daily skilled therapy. This beneficiary does not meet severity of illness 
or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services (A9576, 36415, 82565 and 
77049) provided on November 3, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this claim was not billed 
according to Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services 
correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient hospital services have not been met. Specifically, this claim was billed with CPT 
code 77049. CPT code 77049 has a status indicator of B which means that payment is never made for this 
service when billed on an outpatient hospital claim. Therefore, we decided that the Plan does not have to pay 
for the outpatient hospital services (A9576, 36415, 82565 and 77049) provided on November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair purchased on September 27, 2021. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is needed for mobility. The Plan denied 
your request. The Plan says this can only be rented. 
 
The Plan must follow Medicare rules. The rules say that as of January 1, 2011, standard power wheelchairs are 
only available as capped rental items. Lump-sum purchase is not permitted.  
 
In this case, the Plan has approved coverage for rental of a power wheelchair. We encourage you to contact the 
Plan to arrange for rental of a power wheelchair. However, the power wheelchair you have requested cannot be 
provided through a lump-sum purchase. Therefore, we decided that the Plan does not have to pre-approve a 
power wheelchair purchased on September 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on September 26, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would 
like this decision to be reconsidered. The Plan denied your request. The Plan says since there was no transport, 
ambulance charges are not covered. The Plan also says that the Medicare ambulance benefit is a transportation 
benefit and without transport 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 September 26, 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 with no 
transport (A0998) provided on September 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aptiom for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested drug is intended for patient self-administration. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Aptiom for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (81000, G0483) provided on 
November 20, 2020. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed according to 
Medicare guidance. 
 
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 drug testing 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. Additionally, CPT 
code 81000 is a column II code to column I code G0483. CPT code 81000 has not been billed with a modifier 
to bypass this edit and is not separately reimbursable. Therefore, we decided that the Plan does not have to pay 
for the drug testing services (81000, G0483) provided on November 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for allograft services (procedure code 20931) provided to the 
enrollee on September 9, 2021. 
 
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 procedure code 20931 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 20931 is "Allograft, structural, for spine surgery only 
(List separately in addition to code for primary procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report has conflicting 
documentation and therefore does not support a structural allograft. The operative report procedure description 
states "Use of commercially available morcellized autograft material", and the procedure states "We achieved 
adequate epidural hemostasis, measured in the discectomy defect, picked out the appropriately sized biomechanical interbody device, which was filled in its center with commercially available morcellized 
allograft material." Morcelized are small pieces of bone used to opack defects and promote new bone growth, 
and structural graft is a single piece of bone, which provides direct support for skeletal structures.  There is also 
a different between an autograft and allograft, which is both documented in the operative report. 
 
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 allograft services (procedure code 20931) provided to the enrollee on September 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 28, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim to be reprocessed 
for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment 
of all Medicare covered services related or unrelated to the enrollees terminal condition. 
 
  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 medical services provided on April 28, 2021.