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

 
We decided that the Plan does not have to pay for the x-ray exam of the cervical spine (72040) and the x-ray 
exam of the knee (73560) provided on August 30, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the x-ray exam of the cervical spine (72040) and the x-ray exam of the 
knee (73560) provided on August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enteral infusion pump billed with code B9002 for 
September 23, 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 modifier RR must be billed when durable medical 
equipment (DME) is to be rented. 
 
We looked at the file and Medicare rules. The file shows that code B9002 was not billed with the required -RR 
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 enteral infusion pump billed with 
code B9002 for September 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 24, 2022, to 
April 22, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 24, 2022, to April 
22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with codes 82607, 84436, and 84443 for 
date of service August 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says these services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The tests at issue in this appeal were requested solely for screening purposes. This is evidenced by the fact that 
the only diagnosis billed on the claim was Z00.00, which is just a general adult medical exam without 
abnormal findings. Medicare does not cover these tests solely for screening purposes. Therefore, we decided 
that the Plan does not have to pay for lab services billed with codes 82607, 84436, and 84443 for date of 
service August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care billed with code 99223 for October 
12, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not payable. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician. 
 
We looked at the file and Medicare rules. The file shows that code 99223 was billed on the same day as code 
99291 by a physician in the same provider group. Code 99223 cannot be covered with 99291 in this instance. 
Therefore, we decided that the Plan does not have to pay for the initial hospital care billed with code 99223 for 
October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation and report billed with code 
85060 for August 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the file 
shows the services were not provided to a hospital inpatient. Therefore, we decided that the Plan does not have 
to pay for the blood smear interpretation and report billed with code 85060 for August 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 17003 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for procedure code 17003. You say that procedure code 17003 is an add on code to 
17000 and cannot be billed alone. You say that procedure code 17000 was allowed for separate reimbursement 
and procedure code 17003 should be allowed for separate reimbursement as well. The Plan denied your 
request. The Plan says payment for code 17003 is bundled into payment for code 17110. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 17003 
is a column II code to column I code 17110. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 17003 billed for date of service July 5, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 19, 2022, to 
April 27, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the documentation supports this 
inpatient admission as reasonable and medically necessary within the accepted standards of clinical care. The 
Plan denied your request. The Plan says that the outlier is not payable because at least 15 claimed outlier days 
did not meet medical necessity and level of care. 
 
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 the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found although the enrollee appeared to be somewhat stable, they had significant 
leukocytosis that was suspected to be of infectious origin. Our reviewer also found that the enrollee's 
medications were changed on April 6, 2022, which requires additional hospital monitoring and care that would 
be expected to cross at least 2 additional 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 the acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from March 19, 2022, to April 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on 
August 2, 2022. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The targeted genomic sequence analysis panel at issue in this appeal was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the targeted genomic sequence analysis panel provided on August 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face-down recovery chair purchased on August 23, 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 provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
dates of service at issue. Therefore, we decided that the Plan does not have to pay for the face-down recovery 
chair purchased on August 23, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary for the enrollee as they 
need more extensive care for their medical problems. The Plan denied your request. The Plan says the enrollee 
can receive further therapy services in a lower level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled therapy needs. Daily skilled services 
are not 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on September 8, 
2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that there is no copayment for your 
routine eye exam which includes the eye refraction. The Plan denied your request. The Plan says this cost 
sharing was charged 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 clearly says that you must pay a $35 
copayment for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $5 copayment, which is less than the standard amount, for the eye exam. This 
eye exam falls within the vision care benefit category. The medical record shows a cataract diagnosis which 
makes the eye exam medical in nature. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the eye 
exam and provided on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4208, A4649, and 96372 billed for date of 
service July 8, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 A4208 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A4208 is statutorily excluded from Medicare payment. 
 
Procedure code A4649 has a Status Indicator of P on the Physician Fee Schedule. This means that payment for 
procedure code A4649 is excluded/bundled. 
 
Procedure code 96372 has a PC/TC indicator of 5 and is incident to physicians' services. This means that 
payment cannot be made for this code when furnished to a hospital inpatient or outpatient. The file shows that 
the services were performed in the outpatient hospital setting. 
 
 
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 procedure codes A4208, A4649, and 96372 billed 
for date of service July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ottobock hand pad and height adjustable push 
handles (K0108). 
 
You asked the Plan to pre-approve a hand pad and push handles. You say that you disagree with the denial. The 
Plan denied your request. The Plan says these items do not serve a medical purpose and cannot be 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 ottobock hand pad and height adjustable push handles 
(K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 63048 billed for date of service September 7, 
2022. 
  You asked the Plan to pay for procedure code 63048. You say that authorization was obtained for code 63048 
and the operative report shows work was done on multiple levels. You say that you expect payment for this 
code. The Plan denied your request. The Plan says payment for code 63048 is bundled into payment for code 
22633. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 63048 
is a column II code to column I code 22633. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 63048 billed for date of service September 7, 
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 August 21, 
2022. You asked the Plan to pay for procedure code 99100. 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 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service August 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power 
wheelchair. 
 
You asked the Plan to pre-approve power seat elevation feature. You say that you need this. The Plan denied 
your request. The Plan says this feature is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation features are not covered by 
Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation feature (E2300) for a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital inpatient or observation discharge day management 
(99239) provided on July 28, 2022. 
 You asked the Plan to pay for hospital discharge management. You say that this service was billed with an 
appropriate place of service. The Plan denied your request. The Plan says this claim was billed with an 
inconsistent place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that generally, services should be billed with a place of service (POS) code which reflects where the 
enrollee received the face-to-face service. However, if the enrollee is registered inpatient or outpatient of a 
hospital, the correct POS code, regardless of where the face-to-face service occurs, is that of the appropriate 
inpatient or outpatient POS code. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, this claim was billed with 
POS code 22 (on campus- outpatient hospital). However, there is an inpatient claim on file for the enrollee for 
July 26, 2022, through July 28, 2022, and the medical records show that the enrollee was being discharged 
from inpatient care on the date in question. Based on this information, we decided that Medicare rules for 
coverage of hospital discharge management have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital inpatient or observation discharge day management (99239) provided on July 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted navigation/image guidance 
(MAKOplasty) (CPT code 0055T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the current evidence-based medical literature does not support the routine 
use of computer-assisted surgical navigation (e.g., MAKOplasty/MAKO Tactile Guidance System) in total 
joint arthroplasty. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found computer assistance is not medically needed in total shoulder surgery. It has not been 
demonstrated to be more effective than conventional open surgery. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computer-assisted navigation/image guidance (MAKOplasty) (CPT code 0055T).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (81455) provided on July 28, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this testing was medically necessary and is 
supported in the medical records. The Plan denied your request. The Plan says that they were unable to render a 
decision on this case within the allotted time frame. 
 
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. Specifically, the Plan has not provided a clear reason for denial in this case, nor 
has the Plan submitted any supporting evidence or citation to support the denial of this claim. Therefore, we 
decided that the Plan has to pay for laboratory services (81455) provided on July 28, 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.