Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 home health physical therapist visits. 
 
You asked the Plan to pre-approve 10 home health physical therapist visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 10 home health physical therapist visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
does not have documented, ongoing, home health physical therapist needs. Skilled services are not shown to be 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs can be provided at a lower 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 10 home health physical therapist visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 10 home health physical therapist visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on  May 11, 
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 place of service was reported 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. 
 
The outpatient place of service (22) was reported in this case. However, the records support that the enrollee 
was inpatient at this time. 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 ultrasound services 
provided to the enrollee on  May 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on April 1, 2022, to April 
26, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB code. Therefore, we decided that the Plan does not have to pay for the home health services rendered on 
April 1, 2022, to April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service April 29, 
2022, to May 2, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this is a payable code. The Plan denied your 
request. The Plan says the billed code is invalid 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 procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service April 29, 2022, to May 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered on August 25, 2020. 
 
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 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the record shows that the 
services were performed in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on August 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic panel provided on March 16, 2022, billed with 
code 0037U. 
 
You asked the Plan to pay for the genetic panel. You say that this is an approved test that is covered by 
Medicare. The Plan denied your request. The Plan says the claim was not billed correctly. 
 
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. The unique identifier should be reported on the 
claim. 
 
We looked at the file and Medicare rules. The claim does not include the unique identifier assigned to this test. 
Based on this information, we decided that Medicare rules for coverage of the genetic panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic panel provided on March 16, 2022, 
billed with code 0037U.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy. 
 
You asked the Plan to pre-approve HBO therapy. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to specific 
conditions. 
 
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 HBO therapy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has a persistent urethral-rectal fistula following prostatectomy. The noted diagnosis is not an 
enumerated condition for which coverage is available and therefore, coverage of the requested service is 
excluded by rule. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 3 home health physical therapy visits. 
 
You asked the Plan to pre-approve an additional 3 home health physical therapy visits. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 additional 3 home health physical 
therapy visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found in 
this case, the documentation does not support that you require additional skilled rehabilitation services to 
provide treatment that is medically necessary. You do not require additional skilled rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance 
program to maintain your condition and/or prevent deterioration. You have been medically stable without any 
recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are 
not medically 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 additional 3 home health physical therapy visits have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an additional 3 home health physical therapy 
visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on May 3, 2022. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. The Plan denied your request. The Plan 
says this type of provider is not part of the Medicare Program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services (A0432) provided on May 14, 
2022. 
 
You asked the Plan to pay for paramedic intercept services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services at issue are not a covered benefit. 
   
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services (A0432) provided on May 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 75716-XU billed for date of service May 2, 2022. 
 
You asked the Plan to pay for code 75716-XU. You say that modifier XU was appended appropriately, so this 
code should be paid. The Plan denied your request. The Plan says The use of the XU modifier is not 
appropriate in this case to allow for separate payment of code 75716. This code is included in code 37224 and 
is not separately reimbursed. . The medical records received do not support that the procedure or service was an 
unusual non-overlapping service from the other services performed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -XU modifier if 
the service billed with the modifier indicates an unusual non-overlapping service,.   
 
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 code 75716-XU Our reviewer says that the 
use of modifier XU is not supported in this case. Our physician reviewer found This procedure code is included 
in the billed procedure code 37224 and the XU would not be appropriate to overcome the edit as it was not 
separate and distinct  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 75716-XU have not been met. Therefore, we decided that the Plan does 
not have to pay for code 75716-XU billed for date of service May 2, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the COVID-19 screening services provided 
November 19, 2021. 
 
You asked the Plan to reimburse you for the screening services. You say that you traveled to Seattle, 
Washington and unfortunately your test results expired by a few hours by the time you arrived at the Seattle 
airport. You were all required to new COVID test which you paid a total of $500. You are requesting 
reimbursement. The Plan denied your request. The Plan says this cost sharing was reimbursed correctly. 
 
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 says that when you send a request for 
payment, the Plan will review your request and decide whether the service or drug should be covered. If the 
Plan decides it should be covered, the Plan will pay their share of the cost for the service or drug.  
You are requesting to be reimbursed $500 for the screening services. The records provided show that the cost  
for the individual test was $82.95. The Plan reimbursed $51.31 which is the Medicare allowed amount for the 
individual test provided in the records. This item/service falls within the Outpatient diagnostic tests and 
therapeutic services and supplies 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 reimburse you for the 
COVID-19 screening services provided November 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on February 11, 
2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule. 
 
The service at issue in this appeal was billed with CPT code 35092. This code is listed with a status indicator of 
C on Addendum B of the 2022 OPPS/ASC final rule. This means the service has been designated as 
inpatient only, and therefore must be billed as part of an inpatient admission. The services were billed on an 
outpatient claim. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services 
provided on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 15, 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 81455 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 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes 
(eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, 
KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), 
interrogation for sequence variants and copy number variants or rearrangements, if performed. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the specimen was not 
collected on the billed date of service. 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 laboratory 
services rendered on April 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305-26-59) provided on February 
8, 2022. 
 
You asked the Plan to pay for procedure code 88305-26-59. You say that you would like the Plan to reconsider 
their denial of payment. 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 the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services (88305-26-59) provided on February 8, 2022, have been met. We looked at the file and Medicare rules. In this case, there were 
no medical records provided confirming that two separate surgical pathology procedures (88305) were 
provided February 8, 2022, by this provider. The file shows that the Plan paid for one claim submitted with 
code 88305 by this provider. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (88305-26-59) provided on February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 27870, 28725, and 28730 billed for date of 
service December 17, 2021. 
 You asked the Plan to pay for procedure codes 27870, 28725, and 28730. The Plan denied your request. The 
Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 27870, 28725, and 28730 is 1. The MAI value for these codes is 2. You 
billed 2 units of each of these codes, exceeding the MUE. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 27870, 28725, and 28730 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 27870, 28725, and 28730 billed for date of service December 
17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided [ENTER DATES 
OF SERVICE]. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency department on May 21, 2022 with a 
complaint of intermittent dizziness. His vital signs were stable and the neurological exam was non-focal. The 
laboratory studies were unremarkable. He was admitted for dizziness and opioid intoxication. The record does 
not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's 
necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided [ENTER DATES OF SERVICE].
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87798, 87799, 87482) provided on June 
1, 2022. 
 
You asked the Plan to pay for lab services. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 87150, 87798, 87799, and 87482 is not supported in the medical record. Specifically, 
multiple unbundled codes were submitted for a single panel. Based on this information, we decided that 
Medicare rules for coverage of lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (87150, 87798, 87799, 87482) provided on June 1, 2022.