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

 
We decided that the Plan does not have to pay for psychotherapy provided on May 3, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent of declination date to consultations, and the date of consultation in the patient's medical record. There 
was no documentation of contact in the patient record. 
 
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 psychotherapy 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. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on May 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
provided records do not document any acute or unstable medical conditions or changes in medication or 
treatment which would necessitate any further skilled nursing visits beyond what has already been approved. 
The records document that you and caregiver have been educated on your disease process and medications. 
There are no medical notes from your treating physician providing documentation of an order or need for 
additional skilled nursing services.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six home health skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 July 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).  
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation showing lymphedema extending onto the chest, trunk, and/or 
abdomen. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records from the enrollee's treating physicians do not document any lymphedema of the 
chest, trunk, or abdomen. As records do not document lymphedema of the chest, trunk or abdomen or trial and 
failure of a standard pneumatic compression pump, then it cannot be said that the enrollee has unique 
characteristics that would indicate a segmented pump over a standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73100-26-LT representing radiological 
examination of the left wrist provided on December 21, 2021. 
 
You asked the Plan to pay for procedure code 73100-26-LT representing radiological examination of the left 
wrist. You say that the services were medically necessary. The Plan denied your request. The Plan says this 
claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 3, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 73100-26-LT representing radiological examination of the left wrist have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 73100-26-LT representing radiological examination of the left wrist provided on 
December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on April 21, 
2022. 
 
You asked the Plan to pay for the CXbladder detect test. You say that this service was medically necessary and 
covered by Medicare. The Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CXbladder detect test have not been met. Therefore, we 
decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on April 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical procedure codes 20930, 22558, 22850, 63047 
provided to the enrollee on September 21, 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. 
 
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 20930: 
 
Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in 
addition to code for primary procedure) 
 
 
 CPT 22558: 
 
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for 
decompression); lumbar 
 
CPT 22850: 
 
Removal of posterior nonsegmental instrumentation (eg, Harrington rod) 
 
CPT 63047: 
 
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar 
 
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 all of the denied codes were not 
supported in the operative note. There is no documentation of anterior lumbar fusion, removal of 
instrumentation, nor lumbar laminectomy. 
 
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 surgical procedure codes 20930, 22558, 22850, 63047 provided to the enrollee on September 
21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services (99238) provided on August 8, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that this service was medically necessary and 
should be covered. The Plan denied your request. The Plan says the code billed is not supported by the records. 
 
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 99238 is Hospital Discharge management. 
 
We find that CPT code 99238 is not supported in the medical record. Specifically, another doctor already billed 
for this service. The records show the patient was discharged on August 9, 2022, not August 8, 2022. Based on 
this information, we decided that Medicare rules for coverage of the inpatient services have not been met. 
Therefore, we decided that the Plan does not have to pay for inpatient services (99238) provided on August 8, 
2022.
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 LTACH setting is necessary to 
perform the necessary care and management as the enrollee's nursing needs well exceed 6.5 hours daily. The 
Plan denied your request. The Plan says the enrollee's records do not show they need continued treatments and 
care that can only be given in a hospital setting. 
 
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 all medically necessary care is being provided in the current acute care setting. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arterial catheterization or cannulation for sampling, 
monitoring or transfusion (separate procedure); percutaneous provided to the enrollee on August 1, 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 code 36620 is "Arterial catheterization or cannulation for 
sampling, monitoring or transfusion (separate procedure); percutaneous." 
 
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 documentation does not 
support that the service in question was rendered. A review of the anesthesia and surgical records provided 
does not reveal a procedure note related to arterial catheterization. 
 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 arterial catheterization or cannulation for sampling, monitoring or transfusion (separate 
procedure); percutaneous provided to the enrollee on August 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is considered 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 31, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim denied as a duplicate in error. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 31, 2022.
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. The Plan denied your request. The Plan says the 
enrollee records do not show it is medically safe to transfer to an LTACH. 
 
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 the medical record does not indicate that the enrollee requires services that the 
enrollee is not receiving currently 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99232) provided on June 25, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says Original Medicare is liable for payment for this service. 
 
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 physician services (99232) provided on June 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bronchoscopy (procedure code 31622) provided to the 
enrollee on January 20, 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 code 31622 is "Bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate 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 that the medical records submitted did 
not include a bronchoscopy report. The code cannot be verified. 
 
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 bronchoscopy (procedure code 31622) provided to the enrollee on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
16, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that these services should be covered under the 
surgeon's and facility's authorization. The Plan denied your request. The Plan says procedure code 99100 is 
considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-bed table (E0274). 
 
You asked the Plan to pre-approve the over-bed table. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this item is non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an over-bed table (E0274).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tiering exception for Heplisav-B. 
 
You asked the Plan to pre-approve a tiering exception for Heplisav-B. You say that the exception is needed. 
The Plan denied your request. The Plan says the medication does not qualify for tier exceptions. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tiering exception for Heplisav-B have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tiering exception for Heplisav-B.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by an out-of-network provider on August 12, 2022.

You asked the Plan to pay for an office visit. You say that the records attached support the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered.

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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided by an out-of-network provider on August 12, 2022.