Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for health behavior intervention services provided to the enrollee 
on March 3, 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 Plan can only approved six units of CPT 96165. 
 
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 96165 is "Health behavior intervention, group (2 or more 
patients), face-to-face; each additional 15 minutes (List separately in addition to code for primary service)." 
 
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 additional units at 
issue in this case were not supported by the medical records. Our reviewer found there is no documentation to 
support a primary or attending physician was involved in the services provided. 
 
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 health behavior intervention services provided to the enrollee on March 3, 2021.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pay for the initial observation care provided on July 24, 2021. 
 
You asked the Plan to pay for the initial observation care. You say that you would like the Plan to reconsider 
their denial of payment. 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. The Plan denied payment for the initial observation services stating the allowed 
units were exceeded. The Plan says that physicians in the same group practice who are in the same specialty 
must bill and be paid as though they were a single physician. However, the Plan only provided two unpaid 
claims for the same provider, the original claim and one the Plan reprocessed, neither claim being paid to the 
provider. The Plan has not provided any evidence that observation care was paid for on any claim in order to 
deny units being exceeded. Therefore, we decided that the Plan has to pay for the initial observation care 
provided on July 24, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says until the efficacy of this device has been established, this cannot be approved.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the procedure is considered experimental/investigational and two learned orthopedic societies have
declined to endorse its use. Furthermore, the enrollee is morbidly obese which is a contra-indication according
to the manufacturer. The request is not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the member's face-to-face service was rendered in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
September 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve a PET scan. You say that this testing will evaluate the patient's symptoms of
elevated prostate specific antigen. The Plan denied your request. The Plan says PET scans are not covered for
initial anti-tumor treatment strategy in patients with prostate cancer.
The Plan must follow Medicare rules. Medicare rules say that PET scans for the initial treatment strategy for
prostate cancer are not covered for any reason. Therefore, we decided that the Plan does not have to preapprove
a positron emission tomography (PET) scan..
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a
positron emission tomography (PET) scan.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 
25, 2021, to June 30, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the Plan did 
not receive the initial RAP claim within 5 calendar days from the start of care. Therefore, we decided that the 
Plan does not have to pay for the home health services provided to the enrollee from June 25, 2021, to June 30, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for acupuncture services provided on August 13, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for this service.
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says
that acupuncture requires prior authorization. The Plan did not pre-approve these services. Therefore, we
decided that the Plan does not have to pay for acupuncture services provided on August 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for plastic surgery services provided to the enrollee on August
11, 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 amount of units billed is inappropriate.
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 19340 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for plastic surgery services provided to the enrollee on August 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 20, 
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 service should not be unbundled. 
 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 imaging services provided to the enrollee on September 20, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary The 
Plan denied your request. The Plan says the enrollee can be managed at their current acute inpatient hospital 
facility. The Plan contends that the enrollee is improving and should be able to soon transition to a lower level 
of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the enrollee does not meet criteria for LTACH services. Our physician reviewer found the enrollee is 
receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81404, 81405, 81406, and 81479) 
provided on July 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (81404, 81405, 81406, and 81479) provided on July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that this scan is needed to determine if disease has 
spread to the patient's pelvis, necessitating radiation treatment. The Plan denied your request. The Plan says 
PET scans are not covered for initial staging of prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans for the initial treatment strategy for 
prostate cancer are not covered for any reason. Therefore, we decided that the Plan does not have to pre-
approve  a positron emission tomography (PET) scan.. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a positron emission tomography (PET) scan.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 26, 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 provider did not bill 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 70596. 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 imaging services provided to the enrollee on October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 21,
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 this code is considered inclusive to another 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 code 43999 is "Unlisted procedure, stomach."
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 the operative report describes a
Volvulus reduction, gastropexy and gastrostomy was performed, and the unlisted procedure is being reported
for the gastropexy. The documentation does not support the gastropexy as a separate procedure from the
volvulus.
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 provided to the enrollee on September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multi-positional patient support system with an 
integrated patient lift. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says a stair lift does not serve a primarily medical purpose and therefore, this denial is upheld 
as not reasonable and necessary. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not reveal that without this item, you would be bed-confined. Additionally, the documentation does not reveal an objective physical examination of you, including a gait exam. The request 
appears to exceed your medical needs. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a multi-positional patient support system with an integrated patient lift.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a left genicular nerve block provided to the enrollee on May
26, 2020.
You asked the Plan to pay for the block. You say that this is medically necessary. The Plan denied your
request. The Plan says the clinical value and effectiveness of this request in the setting of chronic knee pain has
not been demonstrated in the peer-reviewed literature.
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 block. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this is considered an experimental/ investigational procedure whose role in the treatment of knee pain is
still being evaluated. Therefore, the procedure was not medically reasonable or 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 the block have not been met. Therefore, we decided that the Plan does not have
to pay for a left genicular nerve block provided to the enrollee on May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83739-59 billed for date of service May 18, 
2021. 
 
You asked the Plan to pay for procedure code 83739-59. You say that these services were medically necessary 
and billed correctly. The Plan denied your request. The Plan says the use of modifier -59 on procedure code 
83789 is not supported by the medical record. There is no evidence that this code was separate and distinct 
from code 80307, which has already been paid. Providers performing validity testing of urine specimens used 
for drug testing should not bill separately for the validity testing. This is an internal control process that is not 
separately reportable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code 83739-59 Our reviewer says 
that the use of the -58 modifier is not appropriate. Our physician reviewer found you reported Current Procedural Terminology (CPT) 83789 Mass spectrometry and tandem mass spectrometry , non-drug analyte(s) 
not elsewhere specified, qualitative or quantitative, each specimen.  Documentation submitted was reviewed, 
and does not meet criteria. Documentation does not support code 83789 as a separate procedure, as validity 
testing would not be separately reported from drug testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 83739-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 83739-59 billed for date of service May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel (87798, 87486, 87541, 87581, 87640, 
87633 and U0004) provided on July 14, 2020. 
 
You asked the Plan to pay for the respiratory panel. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not billed with the appropriate 
place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory panel have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the member's face-to-face service was rendered in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the respiratory panel (87798, 87486, 87541, 
87581, 87640, 87633 and U0004) provided on July 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 13, 
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 code is inclusive to another 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, we have confirmed that code 49653 
is a column II code to column I code 44202. 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 surgical services provided to the enrollee on October 13, 2021.