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

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service October 29, 
2021. 
 
You asked the Plan to pay for procedure code 70544. You say that this is supported in the records. The Plan 
denied your request. The Plan says payment for code 70544 is bundled into payment for code 70553. 
 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 70544 
is a column II code to column I code 70553. 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 70544 billed for date of service October 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a follow up office visit at a tertiary facility (99215) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the physician service. You say that your pacemaker was placed at the 
requested facility. You also say that they are the only ones able to read the signals. The Plan denied your 
request. The Plan says the requested care can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider at issue in this case is not a network provider with the Plan. 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 physician service. Our reviewer says that an office visit at an out-of-
network facility is not medically necessary. Our physician reviewer found the provided documentation does not 
support a need for pacemaker follow-up expertise which could not be provided by network providers, who have 
sufficient expertise to do this. The follow-up can be safely transitioned to the network physician without risk. 
There are credentialed, experienced physicians within your plan network who could be utilized. 
 
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 physician service have not been met.  
 
The Plan has network providers available who can provide the service at issue in this appeal. We found no 
exception that would require the Plan to pre-approve the physician service. Therefore, we decided that the Plan 
does not have to pre-approve a follow up office visit at a tertiary facility (99215) to be provided by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the noninvasive estimated coronary fractional flow reserve 
(FFR) (0503T) provided on December 7, 2021. 
 You asked the Plan to pay for a coronary FFR. You say that the computed tomography angiography (CTA) 
flow study was ordered to assess for obstructive coronary artery disease (CAD). The Plan denied your request. 
The Plan says additional payment does not have to be made. 
 
The Plan follows Medicare rules. Medicare rules say that FFRct technology may be considered reasonable and 
necessary in the management of patients with symptomatic, stable ischemic heart disease (SIHD) when the 
CCTA analysis is completed and demonstrates coronary artery disease. 
 
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 a coronary FFR. Our reviewer says that the 
coronary CTA with FFR is not medically necessary. Our physician reviewer found the CTA showed no 
significant coronary artery disease. The reviewer found that documentation would not support a further need 
for FFR. Therefore, the reviewer found that coronary CTA with FFR (0503T) would not be considered 
medically reasonable and 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 a coronary FFR have not been met. Therefore, we decided that the Plan does not 
have to pay for the noninvasive estimated coronary fractional flow reserve (FFR) (0503T) provided on 
December 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77063, 77067) provided on November 
12, 2021. 
 
You asked the Plan to pay for the radiology services. You say that multiple exams were performed. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. Records do not support multiple exams. 
 
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 December 16, 2021. 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 the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for radiology services (77063, 77067) provided on 
November 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided from November 30, 2021 to December 13, 2021. 
 
  You asked the Plan to pay for IRF care. You say that the overall complexity of the enrollee's medical and 
functional condition at the time of admission validated the need for intensive skilled therapy services in a 
resource intensive inpatient hospital environment. The Plan denied your request. The Plan says medical 
necessity has not been met for the IRF services. 
 
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 pay for 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 the enrollee did not need intensive therapies, consisting of at least 3 hours of therapy 
per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. Our reviewer found 
that an IRF admission was not medically necessary based on medical stability, lack of medical complexity, lack 
of acute rehabilitation nursing needs and high functional level. Our physician reviewer also found that the 
enrollee's rehabilitation needs were at a lower intensity and alternate setting such as in an SNF. 
 
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 pay for acute inpatient rehabilitation facility (IRF) admission and services provided from November 30, 
2021 to December 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 30, 2021, 
to August 4, 2021. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says the 
enrollee did not meet the criteria for an inpatient admission. 
 
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 does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found based on the enrollee being quite stable on admission and only needing 
short-term monitoring during the remaining workup needed, it was not expected that the enrollee would require 
hospital services that would likely cross 2 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 not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from July 30, 2021, to August 4, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management service provided on June 6, 
2022. 
 
You asked the Plan to pay for the service provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says the service was bundled as part of the global surgical 
fee. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 
 We find that CPT code 99231 was provided on the same day as surgical procedure code 44970. CPT code 
99231 was billed with the -25 modifier. If evaluation and management services occur on the day of surgery, the 
physician bills using modifier -57, not -25. Based on this information, we decided that Medicare rules for 
coverage of the service provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the evaluation and management service provided on June 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on August 2, 2021, to 
August 11, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
billing of G93.41 as the secondary diagnosis code is supported. The Plan denied your request. The Plan says 
the billing of secondary diagnosis code, G93.41, metabolic encephalopathy is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, G93.41, defined as 
metabolic encephalopathy. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the billing of secondary diagnosis code, 
G93.41, is not supported. Our physician reviewer found the provided documentation does not include 
reasonable support for the secondary diagnosis of G93.41.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 2, 2021, to August 11, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88341, 88342, and 88360 
provided on May 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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 codes 88341, 88342, and 88360 are not supported in the medical record. Specifically, the 
documentation shows that these codes billed have a professional component/technical component of 1. These 
laboratory services were not billed with an appropriate modifier. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded 88341, 88342, and 88360 provided on May 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. The Plan denied your request. The Plan says 18 
additional visits are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the additional requested therapy generally is not accepted as 
specific and effective therapy for your condition beyond what was approved by the health plan. Our reviewer 
found that you have had prior therapy and the documentation does not reveal that you require the unique skills 
of a professional therapist to safely and effectively provide treatment, that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist beyond what was already 
approved. Our physician reviewer also found that the requested services are not part of a maintenance program, 
and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 
 
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 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 18 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72114 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for procedure code 72114. You say that this is supported in the records. The Plan 
denied your request. The Plan says payment for code 72114 is bundled into payment for code 72082. 
 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 72114 
is a column II code to column I code 72082. 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 72114 billed for date of service March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture and cupping treatments 
provided on April 11, 2022. 
 
You asked the Plan to issue reimbursement 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 you do not meet 
criteria for coverage of the services provided in this case. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture treatment provided in this case have not been met.  Specifically, you did not receive these services due to a diagnosis of chronic low back pain. Therefore, we 
decided that the Plan does not have to issue reimbursement for the acupuncture and cupping treatments 
provided on April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 31, 2021, billed with 
codes 81162, 81191, 81206, 81292, 81295, 81298, 81301, 81317, 81321 and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare rules. 
 
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 31, 2021, billed with codes 81162, 81191, 81206, 81292, 81295, 81298, 81301, 81317, 81321 and 
81401.
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 it is in the enrollee's best interest to skill in place 
than to be taken out of their environment. The Plan denied your request. The Plan says the enrollee does not 
need skilled therapy services 5 days a week, and the enrollee does not need daily skilled nursing care. The Plan 
also says the enrollee's needs can be met at 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 daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), 
amplified probe technique (U0003) provided December 13, 2021 while in Germany. 
 
You asked the Plan to pay for the COVID-19 testing. You say that the test was needed in order to board a plan 
to get home to the USA. The test could not be older than 24 hours before the flight and it was necessary in order to travel. The Plan denied your request. The Plan says plans are not required to provide coverage of 
COVID-19 surveillance testing/screening (including an at-home over-the-counter COVID-19 test), which is 
testing used for public health or social purposes such as employment (return to workplace), education, travel, or 
entertainment. 
 
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 test at issue in this appeal, the COVID-19 testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Medicare does not cover non-diagnostic tests (i.e. testing 
done for public health surveillance purposes). Therefore, we decided that the Plan does not have to pay for the 
infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 
(SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique (U0003) provided December 
13, 2021 while in Germany.