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

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service January 19, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that these services 
were reported appropriately and are supported as billed. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oxygen concentrator (E1390) and a portable oxygen system 
(E0431). 
 
You asked the Plan to pre-approve an oxygen concentrator (E1390) and a portable oxygen system (E0431). 
You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says 
that the services are not covered. 
 
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. In this case, the Plan has not provided enough physical evidence to support the 
denial of the requested services based on Medicare criteria. There is not enough documentation provided to 
verify there was a break in billing for the oxygen equipment. There was insufficient evidence to support the 
enrollee was using this equipment after April 2020. Therefore, we decided that the Plan has to pre-approve an 
oxygen concentrator (E1390) and a portable oxygen system (E0431).  
 
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 an office or other outpatient visit (99204) billed for date of 
service April 26, 2022. 
 
You asked the Plan to pay for an office or other outpatient visit. You say that the service at issue has been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 99204 is: Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter. 
 
We find that CPT code 99204 is not supported. Specifically, the Plan has documented that the enrollee is not a 
new patient of the practice. The service at issue has not been billed appropriately. Based on this information, we decided that Medicare rules for coverage of an office or other outpatient visit have not been met. Therefore, 
we decided that the Plan does not have to pay for an office or other outpatient visit (99204) billed for date of 
service April 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 7, 2022, to 
January 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be paid. 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 January 7, 2022, to 
January 10, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial and subsequent hospital care rendered from July 10, 2022, to 
July 17, 2022. 
 
You asked the Plan to pay for these services. You say that the place of service code is correct. The Plan denied 
your request. The Plan says that the procedure code/type of bill is inconsistent with the place of service. 
 
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 states that the billed procedure codes are inconsistent with the place of 
service; however, the file shows that the services were billed to and rendered at an inpatient rehabilitation 
facility. The Plan has not provided any documentation or binding rules to support that codes 99222 and 99231 
are not covered when billed for this place of service. Therefore, we decided that the Plan has to pay for the 
initial and subsequent hospital care rendered from July 10, 2022, to July 17, 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 train-of-four (TOF) testing provided during 
intraoperative neuromonitoring provided on April 20, 2022, billed with code 95999. 
 
You asked the Plan to pay for the TOF testing as billed. You say that this is correctly billed and should be paid. 
The Plan denied your request. The Plan says this code is not valid for the services rendered. 
 
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 95999 is Unlisted neurological or neuromuscular 
diagnostic procedure. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the TOF testing as billed. Our reviewer says that the code 
billed is not supported. Our reviewer found there is no assigned code for TOF testing, as it is included in the 
primary neuromonitoring procedure and not reported separately. Train-of-four monitoring is considered integral to intraoperative neuromonitoring and/or administration of anesthesia and, therefore, is not separately 
reportable. Train-of-four monitoring does not fit the criteria for CPT code 95999. 
 
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 TOF testing as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the train-of-four (TOF) testing provided during intraoperative neuromonitoring 
provided on April 20, 2022, billed with code 95999.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service February 27, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that these services were medically necessary. 
The Plan denied your request. The Plan says payment for code 99291 is bundled into payment for code 92950.  
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 99291 
is a column II code to column I code 92950. 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 99291 billed for date of service February 27, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Lupron Depot. 
 
You asked the Plan to pre-approve Lupron Depot. You say that the requested drug is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for drugs or biologicals have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, the case record indicates that the requested medication will be dispensed by a pharmacy and will 
be brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve treatment with Lupron Depot.  
 
Benefits for Lupron Depot may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that you were admitted to hospice on November 27, 2022. 
 
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 during this pre-approval request. Therefore, we decided 
that the Plan does not have to pre-approve SNF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service July 13, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 85060. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 85060. Based on this information, 
we decided that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service July 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Pembrolizumab as monotherapy or in 
combination with bevacizumab is not a standard of care. Use is not FDA approved, supported by major drug 
compendia, or the medical literature. studies to date have shown pembrolizumab alone or with bevacizumab 
was well tolerated but of limited benefit. The service is not reasonable or medically 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services 87506, 81514, 87500 and 87653 
provided September 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you have attached the information you 
currently have on file for the enrollee. The Plan denied your request. The Plan says the provider did not submit 
progress notes that are needed in order to determine the clinical utility of the testing. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee was evaluated for acute urinary tract infection 
(N39.0: urinary tract infection, site not specified) and microalbuminuria due to Type 2 diabetes mellitus, 
(E11.29: Type 2 diabetes mellitus with other diabetic kidney complication). Regarding the laboratory studies in 
question, the provider did not submit progress notes that are needed in order to determine the clinical utility of 
the testing. The review has determined that the items/services at issue in this case were not medically 
reasonable or necessary and the laboratory services 87506, 81514 87500 87653 were not supported by the 
medical records. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services 87506, 81514, 87500 and 87653 provided September 21, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve PNS (64555). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says that the enrollee is not a surgical candidate, and that the stimulator is only a late or last 
resort for the enrollee with chronic pain. The Plan states the enrollee's doctors office notes do not say that they 
are not a surgical candidate, and the results of the magnetic resonance imaging (MRI) are required for review. 
The Plan states the enrollee's doctor may request this review after the MRI results are available and there is 
information on why surgery is not an option. 
 
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. It appears that the Plans contracted delegate was provided the records for this 
service and has failed to forward them to support the decision to deny based on no medical necessity. 
Therefore, we decided that the Plan has to pre-approve PNS (64555).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from 
August 6, 2019, to August 17, 2019. 
 
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 claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until July 21, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) services rendered from August 6, 2019, to 
August 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM and related supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of CGMs and related 
supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a CGM and related supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00170, & 96375 billed for date of service 
April 20, 2022. 
 You asked the Plan to pay for procedure code 00170, & 96375. You say that this service was medically 
necessary. The Plan denied your request. The Plan says payment for code 00170, & 96375 is bundled into 
payment for code 40810. 
 
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 codes 
00170, & 96375 are column II codes to column I code 40810. 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 00170, & 96375 billed for 
date of service April 20, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for air ambulance services (A0436, A0431) provided on September 17, 
2021. 
 
You asked the Plan to pay for air ambulance services. You say that secondary payment is due for these 
services. The Plan denied your request. The Plan says that the primary payer paid more than the Medicare 
allowed amount for these services, so no additional payment is due. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare secondary payment amounts are 
determined by a formula and are the lowest of three options.  
 
We looked at the file and Medicare rules. In this case, the providers actual charge is $55,060.60, the primary 
payer paid $5,000, the Medicare fee schedule allowed amount is $4496.39, and the Plans required cost-share 
amount is $290. This means that for option one (the Plan pays the actual charge less the primary payment), the 
Plan payment would be $50,060.60. For option two (the fee schedule allowed amount less the Plans cost 
sharing), the Plan would owe $4206.39. For option three, the Plans payment would also amount to $55,060.60 
in this case as the primary payer has no allowable amount for this service. This means that according to 
Medicare rules, the Plan should pay $4206.39 for these services. Payment made by another entity does not 
waive the Plans responsibility to make payment for covered services. Therefore, we decided that the Plan has 
to pay for air ambulance services (A0436, A0431) provided on September 17, 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.