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

 
We decided that the Plan does not have to pay for the flow cytometry provided on August 15, 2022. 
 
You asked the Plan to pay for the flow cytometry. You say that this claim should be paid. The Plan denied your 
request. The Plan says this service is not covered for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that flow cytometry will only be covered for 
indications listed in the LCD and LCA. 
 
We looked at the file and Medicare rules. In this case the flow cytometry was provided for the enrollees 
diagnosis of anemia in chronic kidney disease (D63.1). This is not a covered diagnosis according to the 
associated LCD and LCA. Based on this information, we decided that Medicare rules for coverage of the flow 
cytometry have not been met. Therefore, we decided that the Plan does not have to pay for the flow cytometry 
provided on August 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extremity veins provided on September 
15, 2022. 
 
You asked the Plan to pay for the duplex scan of extremity veins. You say that the requesting provider should 
be responsible for obtaining authorization. The Plan denied your request. The Plan says that 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.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the duplex scan of 
extremity veins provided on September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950), prefabricated post and core 
(D2954), pontics (D6250), and retainer crowns (D6750) for tooth #7, #8, #9, and #10. 
 
You asked the Plan to pre-approve the dental services. You say that the dental services are necessary for the 
benefit of the enrollee's health. The Plan denied your request. The Plan says your benefit for the requested 
items or services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollee's benefit for the requested item or service was exhausted on the approval date of March 6, 
2023. Therefore, we decided that the Plan does not have to pre-approve the core buildup (D2950), prefabricated 
post and core (D2954), pontics (D6250), and retainer crowns (D6750) for tooth #7, #8, #9, and #10.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Imaging services provided on September 12, 2022, billed 
with codes 74230 and 74240. 
 
You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of imaging services provided have not been met. The procedure is a barium swallow study, and this 
means that it involves the administration of a substance to the enrollee. Therefore, we decided that the Plan 
does not have to pay for Imaging services provided on September 12, 2022, billed with codes 74230 and 
74240.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics on October 28, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for foot orthotics on October 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) and pontic (D6245) for tooth #4, 
#5, and #6 provided on November 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the extraction was covered so a bridge should 
be covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the core buildup and pontic are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) and pontic (D6245) for tooth #4, #5, and #6 provided on November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99226 billed for date of service September 
17, 2022. 
 
You asked the Plan to pay for the billed services. You say that the information supports the level of care 
submitted. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 99226 is subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem.  We find that CPT code 99226 is not supported in the medical record. The medical records show that the 
enrollee was in no acute distress. The records do not show that the enrollee was unstable, developed a 
significant complication or new problem. The records also do not include a detailed interval history. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99226 billed for date of service 
September 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00790 billed for date of service December 3, 
2021. 
 
You asked the Plan to pay for the billed services. You say that a corrected claim was submitted. The Plan 
denied your request. The Plan says the time limit for filing expired. 
 
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 valid claim for the billed services was not filed until December 7, 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 procedure code 00790 billed for date of service December 3, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on October 19, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the patient was transported to the nearest 
facility for high level of care. The Plan denied your request. The Plan says you did not bill the units of service 
correctly for code A0425. 
 
The Plan must follow Medicare rules. Medicare rules say that for codes with a MUE Adjudication Indicator 
(MAI) of 1, this means that the code has a line item edit, meaning that units of the code in excess of the MUE 
must be reported on a separate line with an appropriate modifier in order to be paid. In this case, code A0425 
has a MAI of 1 and an MUE value of 250. This means that a maximum of 250 units of this code can be billed 
on a single line item.  However, you billed 287 units of code A0425 on a single line item, exceeding the MUE.  
Instead, this claim should have been billed with the maximum 250 units on one line, and a second line with the excess 37 units with an appropriate modifier. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services provided on October 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF admission 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 clinical documentation does not specify any complex functional impairments 
or active medical comorbidities. Thus, the complexity of the enrollee's documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. IRF criteria are not met. 
 
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 an IRF admission and services.
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 you have Parkinsons disease and are unable to walk. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary, and your needs can 
be met at an alternate level of care. 
 
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 you do not have any complex functional deficits or active medical issues. Your 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 38724 billed for date of service October 12, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that code 38724 
is included in the global surgery package for procedure 40530. 
 
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. 
 
We looked at the file and the rules. The case file does not include a claim, explanation of benefits, or medical 
records for procedure code 40530. There is insufficient evidence to show that the service at issue, code 38724, 
was done by the same provider as code 40530. There is no indication that code 38724 was performed due to a 
complication following procedure 40530. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan 
has to pay for procedure code 38724 billed for date of service October 12, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor billed for date of service 
October 7, 2022. 
 
You asked the Plan to pay for the billed services. You say that you provide quality products. The Plan denied 
your request. The Plan says the documentation does not support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
We looked at the file and the rules. In this case, the record does not contain a valid physician order, proof of 
delivery, or relevant medical records which support medical necessity for the supplies provided in this case. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the continuous glucose monitor billed for date of service October 
7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 September 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 29874 and 29876 provided on March 25, 2022. 
 
You asked the Plan to pay for codes 29874 and 29876. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not payable as billed. 
 
The Plan follows 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 29874 is a 
column II code to column I code 29879 with a modifier indicator of 0. The column II code is therefore not 
payable. 
 
Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not 
covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 
29876. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for codes 29874 and 29876 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 29874 and 29876 provided on March 25, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 29, 2022, to 
September 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have provided the required 
NOA. 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 August 29, 2022, to 
September 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the medical 
necessity of the requested MRI lumbar spine has not been established in the submitted 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 magnetic resonance imaging (MRI) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging (MRI).
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 the enrollee requires physical and occupational 
therapy to return to their prior level of functioning. You say that the enrollee's needs inpatient rehab to gain 
their independence and improve their overall strength. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and the enrollee's needs can be met at an alternate level of care. 
 
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 have any complex functional deficits or active medical 
issues. The enrollee's needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 provided on date of service August 1, 
2022. 
 
You asked the Plan to pay for procedure code 99153. You say that the doctor's claim should be paid. The Plan 
denied your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. There is no separate payment to the physician for 
CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to 
pay for procedure code 99153 provided on date of service August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service November 
26, 2021. 
 
You asked the Plan to pay for procedure code 99053. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99053 is considered bundled 
and not separately payable. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service November 26, 2021.