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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 skilled nursing 
facility (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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 20985, 27488) provided to 
the enrollee on July 9, 2021. 
 
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 denied codes are inclusive to another billed code. 
 
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 27488: 
 
Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, 
knee 
 
 
 CPT 20985: 
 
Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately 
in addition to code for primary 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records provided do 
not include sufficient documentation to validate CPT 27488-59 was performed as a distinct separate procedure, 
independent of other services provided on July 9, 2021, specifically CPT 27447. CPT 27488 is included as a 
standard of medical/surgical practice in procedure 27447, therefore, it is inappropriate to bill 27488 with a 59 
modifier. In terms of CPT 20985, the medical records indicate that CPT 20985 is inclusive to procedure code 
27447, which was billed and paid by the health plan, therefore, no other reimbursement is allowed.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure code 20985, 27488) provided to the enrollee on July 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 7, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. 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 July 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
14, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 14, 2022.
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 13, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that these codes 
should not be considered part of a hospital outpatient service. 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 this service was provided to the enrollee while 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 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 1, 2022, billed with 
codes 81301, 81292, 81206, & 81162. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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 
February 1, 2022, billed with codes 81301, 81292, 81206, & 81162.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 30, 2022, to 
May 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA is only required for the 
initial visit which was billed on January 30, 2022, and proof of the NOA billed is attached. You say that the 
claim should be reprocessed correctly. 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, an 
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 April 30, 2022, to May 
12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 documentation does not support medical necessity for admission to an IRF. 
The enrollee has no current medical complexity or rehabilitation nursing needs and is functional for mobility.  While the enrollee will benefit from physical therapy and occupational therapy, their rehabilitation needs can 
be safely met in an alternate and low intensity setting such as in-home 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5298) provided on August 10, 2022. 
 
You asked the Plan to pay for a hearing aid (V5298). You say that you find nothing in writing that this claim 
cannot be approved. The Plan denied your request. The Plan says the item you obtained was rendered by a 
provider who is not part of the Plan Hearing vendor network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are ordered through the Plan hearing providers.  
 
We looked at this physician's review, the file, and the Plan's rules. The Plan rules say that hearing aids ordered 
through providers other than the Plan hearing providers are not covered. The record shows that you went to an 
out-of-network provider for our hearing aids.. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid (V5298) have not been met. Therefore, we decided that the Plan does not have to pay 
for a hearing aid (V5298) provided on August 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 77066 and G0279 billed for date of service July 20, 2022.

You asked the Plan to pay for procedure code 77066 and G0279. You say that the records support separate services rendered. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 77066 and G0279 is 1. The MAI value for each of the codes is 2. You billed 2 units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 77066 and G0279 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 77066 and G0279 billed for date of service July 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, 
per 30-minute interval (G0277) and physician or other qualified health care professional attendance and 
supervision of hyperbaric oxygen therapy, per session (99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy and physician attendance. You say that treatment 
for prophylaxis of ORN is indeed a considered indication. The Plan denied your request. The Plan says your 
request is not medically necessary because the enrollees records do not show he has a confirmed diagnosis of 
osteoradionecrosis and is undergoing treatment. The records say the enrollee is not at high risk for ORN, and 
he is declining dental extraction. 
 
The Plan must follow Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber and limited to certain conditions.  
 
We looked at the file and Medicare rules. The NCD provides a list of approved conditions for hyperbaric 
oxygen therapy. The enrollee does not show he has a confirmed condition or diagnosis. Based on this 
information, we decided that Medicare rules for coverage of hyperbaric oxygen therapy and physician 
attendance have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric 
oxygen under pressure, full body chamber, per 30-minute interval (G0277) and physician or other qualified 
health care professional attendance and supervision of hyperbaric oxygen therapy, per session (99183).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says that he enrollee no longer meets the criteria for continued skilled therapy as she had 
reached maximum rehabilitation potential. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that the enrollee still has functional 
impairments; thus, the enrollee continues to require skilled therapy. The enrollee has required changes in 
diuretics and would continue to require skilled nursing. Evaluating therapist recommend continued skilled 
therapy, daily in a skilled nursing facility. From a practical matter, the patient continues to require daily skilled 
services on an inpatient basis in a 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued 
skilled nursing facility (SNF) care.  
 
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 procedure code 88104 billed for date of service March 29, 
2022. 
 
You asked the Plan to pay for procedure code 88104. You say that this service was reported appropriately and 
is supported in the medical record. The Plan denied your request. The Plan says this service cannot be paid as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 88104 is not supported in the medical record. Specifically, there is no evidence in the 
record provided to show that the rendering physician has re-assigned benefits to the hospital to allow the 
facility to bill for the physician services. Based on this information, we decided that Medicare rules for coverage of procedure code 88104 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 88104 billed for date of service March 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 2, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service September 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP Panel (81455) provided on 
March 10, 2022. 
 
You asked the Plan to pay for the Tempus Liquid Biopsy CGP Panel. You say that this genetic testing was 
medically necessary. The Plan denied your request. The Plan says this testing is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that this test is not FDA approved. Based on this 
information, we decided that Medicare rules for coverage of the Tempus Liquid Biopsy CGP Panel have not 
been met. Therefore, we decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP Panel 
(81455) provided on March 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat polysomnogram (PSG). 
 
You asked the Plan to pre-approve the requested PSG. You say that in order to qualify for a hypoglossal 
stimulator, a PSG needs to be done within 24 months of the procedure. The Plan denied your request. The Plan 
says the enrollee's home sleep study from 2019 can be used to see if they qualify for the inspire device. The 
Plan also says there is no evidence that the enrollee had any change in medical condition or weight change to 
warrant another sleep study. 
 
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 requested PSG. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has known obstructive sleep apnea, diagnosed via home PSG in 2019. The enrollee 
has been intolerant of continuous positive airway pressure (CPAP) treatment. There is a plan for hypoglossal 
nerve stimulator for which he has not been evaluated. It is noted that the enrollee's body-mass index (BMI) is 
35. Studies of the stimulator did not include participants with BMI higher than 32. There is no medical need for 
a repeat sleep study at this time. If the enrollee is evaluated and deemed to qualify for the hypoglossal device and a repeat sleep study is needed prior to the procedure, it can be reconsidered at that time. 
 
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 requested PSG have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat polysomnogram (PSG).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 billed for date of service June 14, 
2022. 
 
You asked the Plan to pay for procedure code 99309. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 99309 is bundled into payment for code 90791. 
 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 99309 
is a column II code to column I code 90791. 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 99309 billed for date of service June 14, 2022.