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

 
We decided that the Plan does not have to pay for the diagnostic and physician services provided on July 15, 
2022. 
 
You asked the Plan to pay for the billed services. You say that you have never owed money to anyone. The 
Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 
 In this case, the CPT Code Manual definition of code 93010 is electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. We find that CPT code 93010 was billed with a diagnosis code that is not 
considered medically necessary. Based on this information, we decided that Medicare rules for coverage have 
not been met. 
 
The CPT Code Manual definition of code 76140 consultation on X-ray examination made elsewhere, written 
report. We find that code 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met.  
 
The CPT Code Manual definition of code 96360 is intravenous infusion, hydration; initial, 31 minutes to 1 
hour. We find that code 96360 is not payable when the service is provided to a hospital inpatient or patients in 
a hospital outpatient department. 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 the diagnostic and physician 
services provided on July 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON lab services. You say that you provided medical records to support 
payment. The Plan denied your request. The Plan says 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. 
 
Neither your lab nor the ordering provider is 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 lab services provided on April 22, 2022, 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 moderate sedation services rendered on August 17, 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 3 represents TC only codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services rendered on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional features for a power wheelchair (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the features. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's upper limb strength and function are adequate for the member to be able to 
control the power options using their own switches which are included in the allowance of these power options. 
 
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 features. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record is inconsistent. The enrollee is independent with transfer, which indicates that he has 
sufficient upper extremity strength and range of motion to manage the standard power drive switches on a 
power wheelchair. 
 
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 features have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional features for a power wheelchair (E2311, E2313, E2377).
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 SNF services would assist in your recovery. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
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 nursing needs. The enrollee does not 
have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs, 
custodial and intermittent, can, as a practical matter, 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: 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 the enrollee just had hip surgery and does not have 
assistance at home. The Plan denied your request. The Plan says the enrollee's 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 that the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation. The enrollees care needs can be met 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the semi-electric hospital bed (E0260) provided on March 4, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital bed. You say that the provider told you that you should go to a rehab 
facility, but the social worker said that a semi-automatic bed would work for you with assistance from your 
family. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-
network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
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 semi-electric hospital bed (E0260) provided on 
March 4, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment with Bupivacaine (J3490) billed for date of service 
July 26, 2022. 
 
You asked the Plan to pay for Bupivacaine. You say that the services at issue have been billed correctly for 
payment. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that the Medicare approved amount for procedures with a 
postoperative period includes payment for certain services, specified in the Medicare rules section of this letter, 
related to the surgery when furnished by the physician who performs the surgery. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Bupivacaine have not been met. Specifically, treatment with Bupivacaine is an intra-operative 
service that is normally a usual and necessary part of the injection services which have been paid by the Plan. 
Therefore, we decided that the Plan does not have to pay for treatment with Bupivacaine (J3490) billed for date 
of service July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not considered a standard of care. 
 
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 at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the 
patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable 
and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a 
malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 the MyoPro orthotic device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for parathyroidectomy or exploration of parathyroid(s) (60500) 
provided on March 8, 2022. 
 
You asked the Plan to pay for parathyroidectomy or exploration of parathyroid(s). You say that this was the 
only provider available to perform these services at the time. The Plan denied your request. The Plan says the 
billing provider in this case is a registered nurse (RN), which is not a provider type that is eligible to accept 
payment for these services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for parathyroidectomy or exploration of 
parathyroid(s) (60500) provided on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20610 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code 20610. You say that you have provided medical records proving 
the medical necessity of this service. The Plan denied your request. The Plan says payment for code 20610 is 
bundled into payment for code 20611. 
 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 20610 
is a column II code to column I code 20611. 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 20610 billed for date of service May 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the brain magnetic resonance imaging (MRI) provided on 
June 7, 2022. 
 
You asked the Plan to pay for the MRI. You say that the diagnosis code provided is appropriate. The Plan 
denied your request. The Plan says the claim was not submitted with the correct diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that for conditions that have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology, the etiology diagnosis code 
must be indicated before the manifestation diagnosis code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MRI have not been met. The claim submitted indicates the manifestation diagnosis code 
(F07.81) is the primary diagnosis. However, coding guidelines require that the diagnosis code for the underlying physiological condition must be coded first. Therefore, we decided that the Plan does not have to 
pay for the brain magnetic resonance imaging (MRI) provided on June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the technical component (TC) of the intraoperative 
neuromonitoring (IONM) services provided on January 20, 2022. 
 
You asked the Plan to pay for the TC of the IONM services. You say that the facility is not able to provide this 
service directly, so it cannot be paid for this service. You state that the Plan must pay you directly for the 
services rendered. The Plan denied your request. The Plan says these services must be provided under 
arrangements by the facility. Payment must be requested from the facility for this care.  
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
Although these services may be appropriate, payment for them is made to the hospital which must then furnish 
these services either directly or under arrangements. As such, separate Medicare payment cannot be made for 
the services at issue. Therefore, we decided that the Plan does not have to pay for the technical component (TC) 
of the intraoperative neuromonitoring (IONM) services provided on January 20, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for facility visits provided on December 18, 2021.  
 
You asked the Plan to pay for facility visits provided on December 18, 2021. facility visits. You say that these 
services were medically necessary and should be covered. The facility staff are responsible for getting 
authorization for their patients. The Plan denied your request. The Plan says that prior authorization is needed. 
However, they failed to send us the EOC. 
 
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. The plan did not gather and/or forward information regarding their decision. We 
were not sent the 2021 EOC for this case. Therefore, we decided that the Plan has to pay for facility visits 
provided on December 18, 2021. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on May 10, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 61783 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 61783 is stereotactic computer-assisted (navigational) 
procedure; spinal (List separately in addition to code for primary procedure). 
 
We find that CPT code 61783 is not supported in the medical record. Specifically, the add-on code was not 
billed with a required primary procedure code. 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 
surgical services rendered on May 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on April 13, 2022, to April 14, 
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. Medicare rules say that inpatient only services billed on an outpatient 
claim are not paid. 
 
We looked at the file and Medicare rules. The file shows that the inpatient only procedure was billed on an 
outpatient claim. 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 surgical services rendered on 
April 13, 2022, to April 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the services described by code 73630 
for date of service June 16, 2022. 
 
You asked the Plan to make additional payment for the code 73630. You say that code 73630 is payable and 
should be reimbursed. The Plan denied your request. The Plan says this code is packaged into payment for code 
99283. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 73630 has a status indicator of Q1 in the Outpatient Prospective Payment System. This means it is 
packaged when billed with a code with status S, T, or V. This was billed with code 99283 which has a status 
code of V. Based on this information, we decided that Medicare rules for coverage of the code 73630 have not 
been met. Therefore, we decided that the Plan does not have to make additional payment for the services 
described by code 73630 for date of service June 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the detection test by nucleic acid for multiple types influenza 
virus, each additional influenza virus type or sub-type (87503) and detection test by nucleic acid for respiratory 
syncytial virus, amplified probe technique (87634) billed for date of service January 4, 2022. 
 
You asked the Plan to pay for procedure codes 87503 and 87634. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 87634 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 87634 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 87634 have not been met. Additionally, respiratory testing must not be 
unbundled. Procedure code 87503 has been billed as an individual component rather than as part of the panel. 
Therefore, we decided that the Plan does not have to pay for the detection test by nucleic acid for multiple 
types influenza virus, each additional influenza virus type or sub-type (87503) and detection test by nucleic 
acid for respiratory syncytial virus, amplified probe technique (87634) billed for date of service January 4, 
2022.