Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 7, 2021 billed with 
codes 81225, 81227, 81230, 81240, 81241, 81249, 81291, 81355, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."] 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 7, 2021 billed with codes 81225, 81227, 81230, 81240, 81241, 81249, 81291, 81355, and 81408.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you had authorization approved for dates of 
service March 15, 2022, to May 14, 2022.  You would like the start date of the authorization to be changed to 
March 11, 2022, because that was your first date of service. The Plan denied your request. The Plan says this 
date of service was not authorized. 
 
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 in this case is not a network provider with the Plan. 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 medical services provided on March 11, 2022, by an out-of-
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy services rendered on May 31, 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 97530 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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the 
services were performed in the home setting and there is a more appropriate code for the 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 occupational therapy services rendered on May 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance services provided on April 27, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON ambulance services. You say that you would like the Plan to grant retro 
authorization for this service. The Plan denied your request. The Plan says unauthorized, out-of-network 
services are not covered. Non-emergency ambulance services require prior authorization. 
 
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. 
 
You are not a network provider with the Plan. 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 non-emergency ambulance services provided on April 27, 2022, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home COVID-19 test you purchased on January 26, 
2022. 
 
You asked the Plan to pay for the home COVID-19 test. You say that you used the form on the Plan's website 
for reimbursement and it said that coverage was available as of January 15, 2021. The Plan denied your 
request. The Plan says home COVID-19 tests are only covered from February 1, 2022, forward for Medicare 
Advantage members.  The January 15, 2022, date applies only to commercial insurance plans. 
 
The Plan must follow Medicare rules. Medicare rules say that as of January 15, 2022, Medicare health plans 
may choose to offer coverage of home COVID-19 tests as a supplemental benefit. If the Plan chooses to offer 
this benefit, the Plan's coverage rules apply. In this case, your Plan did not cover home COVID-19 tests until 
February 1, 2022.  You purchased the test in question prior to this date. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home COVID-19 test have not been met. Therefore, we decided that the Plan does not have to 
pay for the home COVID-19 test you purchased on January 26, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 63047) provided to the enrollee on 
November 10, 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 that Current Procedural Terminology (CPT) code 63047-59-AS (1 Unit) remains not supported 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural 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 the services Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found that the 
procedure narrative states the inferior aspect of the L3-L4 facet bilaterally was exposed. The interspinous 
ligament was taken down at L4-5, then a high-speed drill was used to drill down to the inferior aspect of the L4 
spinous process and lamina and the superior aspect of L5. This exposed the ligamentum flavum, which was 
carefully dissected off of the dura for decompression. Then the medial facets were drilled bilaterally and 
completed the removal of ligamentum flavum for bilateral decompression. The remaining bone and ligament 
overlying the right foramen were drilled at L4-5 and visualized the exiting L4 nerve root. The thecal sac and 
the traversing nerve root medially were retracted. The posterior longitudinal ligament was incised. The disc 
material was removed. This procedure was carried out prior to the fusion procedure. Therefore, the 
documentation does support that CPT 63047: laminectomy, facetectomy, and foraminotomy (unilateral or 
bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess 
stenosis]), single vertebral segment, lumbar was distinct from CPT code 22633. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 63047) provided to the enrollee on November 10, 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: 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 enrollee requires ongoing care for 
complex medical issues which are too acute for a lower level of care. The Plan denied your request. The Plan 
says the enrollee is receiving appropriate inpatient acute care and does not require 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he/she is currently receiving care. 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. The requested LTACH services are not medically necessary, reasonable, 
and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively 
only on an inpatient basis. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance transportation provided on 
February 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the non-emergency ambulance transportation. You say that you would like to 
request retro authorization for this service. The Plan denied your request. The Plan says unauthorized, out-of-
network services are not covered.  Authorization is required for non-emergency ambulance services. 
 
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. 
 Your organization is not a network provider with the Plan. 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 non-emergency ambulance transportation provided on February 
4, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from February 19, 2022, to February 27, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you have an authorization and single case 
agreement for this patient, so this claim should be paid. The Plan denied your request. The Plan says that you 
billed the claim with an invalid/incorrect/missing Patient-Driven Groupings Model [PDGM] 
code. T 
 
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 sole basis of the Plan's denial is that you billed an 
invalid/incorrect/missing PDGM code.  However, the Plan has failed to document or explain how it came to 
that conclusion and what the error or omission is.  There were no records provided in the file the Plan sent us, 
so it is impossible to determine what the correct code should be, if indeed there was an error.  The burden is on 
the Plan to thoroughly explain its denial rationale and to provide sufficient documentation to support that 
denial.  The Plan has failed to do so in this case. Therefore, we decided that the Plan has to pay for home health 
services provided from February 19, 2022, to February 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure codes 36005, 37249, 75820) 
provided to the enrollee on June 27, 2020. 
 
You asked the Plan to pay for the servcies. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes are not supported in the 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 the denied codes is: 
 
CPT 36005: 
 
Injection procedure for extremity venography (including introduction of needle or intracatheter) 
 
CPT 37249: 
 
Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each 
additional vein (List separately in addition to code for primary procedure) 
 
CPT 75820: 
 
Venography, extremity, unilateral, radiological supervision and interpretation 
 
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 servcies. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in therms of CPT 36005, the 
operative report includes documentation of injection for venography, however this procedure would be 
inclusive to angioplasty procedure, and therefore cannot be verified. In terms of CPT 37249, the operative 
report does not include documentation of a balloon angioplasty. In this case, there is insufficient documentation 
to confirm procedure. In terms of CPT 75820, billing radiological and interpretation  services in addition to 
intervention performed cannot be verified, as this procedure would be inclusive. 
 
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 servcies have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure codes 36005, 37249, 75820) provided to the enrollee on June 27, 
2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided to the enrollee 
on February 23, 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 patient was enrolled in hospice at this time. 
 
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 skilled nursing facility (SNF) care provided to the enrollee on 
February 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided by a licensed 
professional counselor (LPC) from March 29, 2022, to May 25, 2022. 
 
You asked the Plan to pay for the LPC services. You say that you were told that these services would be 
covered 60%. The Plan denied your request. The Plan says these services were provided by an ineligible 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists. The provider you saw is a 
LPC, which is not a valid provider type for Medicare. As a result, no services from this provider type can be 
paid. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LPC services have not been met. Therefore, we decided that the Plan does not have to pay for 
outpatient mental health services provided by a licensed professional counselor (LPC) from March 29, 2022, to 
May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 17, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are submitting medical documentation to 
support the enrollee receiving the services without authorization. You say you would like to have the claim 
reprocessed and paid. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 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 an office visit provided on June 17, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on March 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that prior authorization has been waived due to 
COVID-19. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance. 
 
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 nursing facility care provided on March 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that a recent magnetic resonance imaging (MRI) shows 
no scarring and the enrollee's doctor feels she will benefit from rehabilitation. The Plan denied your request. 
The Plan says the IRF care is not medically necessary, and your needs can be met at a lower level of care such 
as a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you have a past medical history of diabetes and a remote COVID infection and is 
living at home with weakness. Your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. 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 March 21, 2022.