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

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on October 14, 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 procedure code 99232 is not separately payable. 
 
The rules say that if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a 
modifier is used. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure codes 99232 and 
99233. Code 99232 is a column II code with a modifier indicator of 0 when billed with column I code 99233. 
No separate payment is made for code 99232. Therefore, we decided that the Plan does not have to pay for the 
subsequent hospital care rendered on October 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a substance abuse rehabilitation hospital to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve substance abuse rehabilitation services. You say that there are no network 
providers available. The Plan denied your request. The Plan says they have in-network providers that are 
available to provide for the enrollee's condition. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal.  We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided 
that the Plan does not have to pre-approve admission to a substance abuse rehabilitation hospital to be provided 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiofrequency ablation procedure (64635, 64636) 
provided August 11, 2021. 
 
You asked the Plan to pay for the radiofrequency ablation procedure. You say that this service was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is covered after the patient 
has had at least two (2) medically reasonable and necessary diagnostic Medial Branch Blocks, with each one 
providing a consistent minimum of 80% sustained relief of primary (index) pain. 
 
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 radiofrequency ablation procedure. Our 
reviewer says that the radiofrequency ablation procedure was not medically necessary. Our physician reviewer 
found the enrollee had a single diagnostic set of Medial Branch Blocks which gave her 75% pain relief. 
Coverage requires dual sets of diagnostic Medial Branch Blocks and then 80% pain relief required from each set. 
 
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 radiofrequency ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pay for a radiofrequency ablation procedure (64635, 64636) provided 
August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance provided on October 23, 2020. 
 
You asked the Plan to pay for the services provided. You say that a modifier was appended to indicate a 
separate service. The Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 77003 is fluoroscopic guidance and localization of needle 
or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or 
subarachnoid) (List separately in addition to code for primary procedure). 
 
 
 We find that CPT code 77003 is an add-on code. The claim does not show that the code at issue was billed with 
a payable primary procedure code. Based on this information, we decided that Medicare rules for coverage of 
the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
fluoroscopic guidance provided on October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from October 1, 2020, to October 30, 2020. 
 
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 focus of care based on the visits provider was not on the primary diagnosis 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate diagnosis code. 
 
We find that the denied SNF services are not supported in the medical record. Specifically, the admission was 
reported based on a diagnosis that has already been resolved. The file does not show evidence that the central 
issue for this admission was based on a diagnosis of stage 2 pressure ulcer. The file shows that this issue had 
been resolved by the time of the denied dates of service. 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 skilled nursing facility (SNF) services provided to the enrollee from October 1, 2020, to October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from July 6, 2021, to 
September 12, 2021. 
 
You asked the Plan to pay for these services. You say that you were told these services would be covered and 
the copayment would be $20. The Plan denied your request. The Plan says the services billed by your provider 
are not covered when rendered by a chiropractor.  
 
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 chiropractic services provided from July 6, 2021, to September 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 1, 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 Current Procedural Terminology (CPT) code 0242U (1 Unit) remains not supported. 
 
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 0242U is "Targeted genomic sequence analysis panel, 
solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, 
gene copy number amplifications, and gene rearrangements." 
 
We find that CPT code 0242U is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a 
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11).  
 
 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 laboratory services provided to the enrollee on 
June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 30, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported crown (D6056) for tooth # 19. 
 
You asked the Plan to pre-approve the dental service. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says abutment supported crown is not listed as a covered 
service. 
 
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. 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested abutment supported 
crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve an abutment supported crown (D6056) for tooth # 19.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 1, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the provider did not 
submit the lab/test results and requisition/order. 
 
The Plan must follow Medicare rules. Medicare rules say that while a physician order is not required to be 
signed, the physician must clearly document, in the medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on June 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission for right shoulder arthroplasty with 
biceps tenodesis. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the health plan feels that the denial of the requested elective inpatient 
admission was appropriate given the clinical scenario. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. The enrollee is undergoing a planned right total 
shoulder arthroplasty with biceps tenodesis. The enrollee is medically stable and has been provided medical 
clearance to undergo this elective procedure. The planned procedure listed under CPT code 23430 and 23472 is 
not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. 
There is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient admission for right shoulder arthroplasty with biceps tenodesis.
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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility. The enrollee does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. 
 
  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a laparoscopy provided on June 29, 2021. 
 
You asked the Plan to reduce the copayment for a laparoscopy. You say that you were told by your insurance 
company you owed $299.18. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient surgery.   
 
You have been asked to pay a $325 copayment for a laparoscopy. A laparoscopy falls within the Outpatient 
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to reduce the copayment for a laparoscopy provided on 
June 29, 2021.  
 
Your complaint about the Plans customer service and receiving incorrect cost share amounts is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 27, 
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 as required 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 81400, 81404, 81405, 81406 are column II codes to column I code 
81411. Additionally, it appears that CPT 81413 is a column 1 code to column II code 81439. This claim has not 
been billed with an appropriate modifier to bypass the edit.  
 
In terms of CPT 81406, 81407, 81408, 81411, 81439, and 81238, there is no evidence that a physician ordered 
these services. Additionally, the place of service on the CMS-1500 form must reflect the location of the patient 
when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while 
the records reflect of place of service of a doctor's office (POS 11). 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory services provided to the enrollee on January 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 23, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
 
 
 
  
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on June 23, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of the magnetic resonance imaging (MRI) of the right 
shoulder provided on October 4, 2021, billed with code 73221-26-RT. 
 
You asked the Plan to pay for the MRI interpretation. You say that this was billed correctly and should be paid. 
The Plan denied your request. The Plan says that this code was billed with a right-sided modifier, but the 
diagnosis code is billed as C64.9, Malignant neoplasm of unspecified kidney, except renal pelvis. This code 
should be reported for right sided malignant neoplasm. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill in accordance with ICD-10-
CM guidelines. The guidelines indicate that for diagnosis codes which indicate laterality, unspecified side 
should only be used when the side is not specified in the records. 
 
In this case, we find that the Plan's denial rationale is not applicable. Review of the record does not show that 
the malignant neoplasm is right-sided. This procedure code is for the right shoulder, not the right kidney area. 
The primary code is also noted to be "Secondary malignant neoplasm of bone" which does not include 
laterality. We find that the use of the diagnosis code C64.9 is supported by the record and that it would not be 
appropriate based on the available information to report this as a right-sided condition. Therefore, we decided 
that the Plan has to pay for the interpretation of the magnetic resonance imaging (MRI) of the right shoulder 
provided on October 4, 2021, billed with code 73221-26-RT.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service.  
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 22850 
is a column II code to column I code 22840. 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 services provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for a vascular consult. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says a vascular consult is available in the plan's network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for a vascular consult.