Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
February 22, 2022. 
 
  You asked the Plan to pay for the determination of refractive state. You say that you feel this should be covered 
because you had pain, blurred vision, and swelling in your right eye. The Plan denied your request. The Plan 
says you received a routine vision exam (92004) on February 19, 2022, and your eye exams and refractions 
benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers 1 routine eye exam(s) with refractions every year. 
 
We looked at the file and the Plan's rules. The record shows that you received a routine vision exam (92004) on 
February 19, 2022, and your eye exams and refractions benefit has been exhausted. Based on this information, 
we decided that the Plan's rules for coverage of the determination of refractive state have not been met. 
Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) 
provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97163-GP-KX billed for date of service 
October 8, 2021. 
 
You asked the Plan to pay for procedure code 97163-GP-KX. You say that this claim was underpaid. The Plan 
denied your request. The Plan says procedure code 97163-GP-KX is not supported by the medical record. The 
appropriate code should have been G0157 
 
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 97163-GP-KX is physical therapy evaluation high 
complexity, requiring these components: a history of present problem with 3 or more personal and/or 
comorbidities that impact the plan of care; An examination of body systems using standardized tests and 
measures addressing a total of 4 or more elements from any of the following: body structures and functions, 
activity limitations, and/or participation restrictions; a clinical presentation with unstable and unpredictable 
characteristics, and clinical decision making of high complexity using standardized patient assessment 
instrument and/or measurable assessment of functional outcome. 
 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 procedure code 97163-GP-KX. Our reviewer says that code 
97163-GP-KX is not supported in the medical record. Our reviewer found the therapy note does not include the 
credentials of the therapist providing this service, therefore this procedure code cannot be verified.  The 
medical documentation includes a name; however, no credentials are documented. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 97163-GP-KX have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 97163-GP-KX billed for date of service October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210), a comprehensive oral evaluation 
(D0150), and a panoramic radiographic imaging (D0330), provided by an out-of-network provider on February 
8, 2022. 
 
You asked the Plan to pay for an extraction, a comprehensive oral evaluation, and a panoramic radiographic 
imaging. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says this 
claim has been processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a 
comprehensive oral evaluation and a panoramic radiographic imaging when the services are provided by a 
participating provider. The Plan does not cover an extraction.  
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an extraction, a comprehensive oral evaluation, and a panoramic radiographic imaging have not 
been met. Therefore, we decided that the Plan does not have to pay for an extraction (D7210), a comprehensive 
oral evaluation (D0150), and a panoramic radiographic imaging (D0330), provided by an out-of-network 
provider on February 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies purchased on January 4, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that the items should be covered. The Plan 
denied your request. The Plan says the claim was filed untimely. 
 
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 the wound care supplies was not filed until January 10, 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 wound care supplies purchased on January 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you need additional routine transportation. 
The Plan denied your request. The Plan says additional trips beyond 20 one-way allowed trips are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (70450) provided on November 
10, 2021. 
  You asked the Plan to pay for the computed tomography (70450). You say that the attached medical records 
should be reviewed, and the claim reconsidered for payment. The Plan denied your request. The Plan says an 
appropriate modifier was not billed with this code edit. 
 
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 70450 
is a column II code to column I code 70496. 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 the computed tomography (70450) provided on November 10, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81227, 81230, 81240, 81241, 
81249, 81291, 81335, 81355, and 81408 provided on November 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81227, 81230, 81240, 81241, 81249, 81291, 81335, 81355, and 81408 are not 
supported in the medical record. Specifically, the documentation supports that molecular pathology testing was 
provided. When a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will 
be considered part of the same panel. A panel constitutes a single procedural service, so one code must be 
submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 81227, 81230, 81240, 81241, 81249, 81291, 81335, 81355, and 81408 provided on 
November 8, 2021.
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 you need these services so you can regain maximum 
function. The Plan denied your request. The Plan says that the services you need such as therapy, can be 
provided safely in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a tibial 
fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria 
for IRF 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 electrodes (A4556) provided on August 9 and September 9, 
2021. 
 
You asked the Plan to pay for electrodes. You say that the items at issue were a medical necessity for the 
enrollee. 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. 
 
 
 We find that CPT code A4556 has a status indicator of P on the Physician Fee Schedule. This means that CPT 
code A4556 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of electrodes have not been met. Therefore, we decided that the Plan does not have to pay for electrodes 
(A4556) provided on August 9 and September 9, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on October 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that If more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported.  
 
We looked at the file and Medicare rules. In this case, the requested services (99285) were provided on the 
same date by a physician or the same specialty within the same group practice, as services (99291) already paid 
by the Plan. In this case, only one E&M service is payable. 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 the services (99285) provided on October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay provided from July 26, 2021, to July 29, 
2021 by an out-of-network (OON) facility. 
 
You asked the Plan to pay for the inpatient stay. The Plan denied your request. The Plan says a request for pre-
approval was not initiated as required by the Plan. The Plan also says that without the request or granted pre-
approval, post stabilization care after July 26, 2021 cannot be approved. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient stay. Our reviewer says that the 
post-stabilization care provided by the OON facility was not medically reasonable and necessary. Our 
physician reviewer found the enrollee was hemodynamically stable and appropriate for ambulance transport 
with monitoring to an in-network facility after the emergency room evaluation on July 26, 2021. Our reviewer 
found that there was no documentation provided indicating medical necessity for post-stabilization care 
services from July 26, 2021, to July 29, 2021 at the OON facility. Our physician reviewer also found that the 
treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not 
stable for transfer on any dates of service. 
 
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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient stay provided from July 26, 2021, to July 29, 2021 by an out-of-network 
(OON) facility.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower 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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for right knee cellulitis. Your 
medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain without 
contrast (70450) provided on February 24, 2022. 
 
 
 
 
 You asked the Plan to pay for the CT without contrast. You say that the enrollee had multiple exams on the 
date in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 
1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 70450 
is a column II code to column I code 70496. 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 computed tomography (CT) of the head or brain without contrast 
(70450) provided on February 24, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to reimburse you for the 6 over the counter (OTC) coronavirus antigen tests that 
you purchased on January 18, 2022. 
 
You asked the Plan to reimburse you for the OTC coronavirus tests. You say that you can the coronavirus in 
January. You also say that this is why you had to purchase the at-home coronavirus tests. The Plan denied your 
request. The Plan says that the coronavirus tests were purchased prior to when coverage was in effect. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans and insurers are required to cover at-home 
over-the-counter COVID-19 tests purchased on or after January 15, 2022.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the OTC coronavirus tests have been met. Therefore, we decided that the Plan has to reimburse 
you for the 6 over the counter (OTC) coronavirus antigen tests that you purchased on January 18, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service February 15, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service February 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 
24-hour facility in addition to basic services (99053) provided on April 1, 2021. 
 
You asked the Plan to pay for the services provided between 10:00 PM and 8:00 AM at 24-hour facility. You 
say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan 
says CPT code 99053 has a status indicator of B. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the services provided between 10:00 PM and 8:00 AM at 24-hour facility have not been met. Therefore, we 
decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-
hour facility in addition to basic services (99053) provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture rendered on October 29, 2021. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. The Plan 
covers up to 12 visits in 90 days for the treatment of chronic low back pain.  
 
We looked at the file and Medicare rules. The file shows that the services were not performed by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Based on this information, we decided that the 
rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acupuncture rendered on October 29, 2021.