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

 
We decided that the Plan does not have to pay for the aflibercept (J0178), injection (67028), and scanning 
computerized ophthalmic diagnostic imaging (92134), provided on June 30, 2021 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the aflibercept, injection, and scanning computerized ophthalmic diagnostic 
imaging. You say that the services were medically necessary. The Plan denied your request. The Plan says 
prior authorization must be obtained for non-emergent services provided by an out-of-network provider. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the aflibercept (J0178), injection (67028), and 
scanning computerized ophthalmic diagnostic imaging (92134), provided on June 30, 2021 by an out-of-
network (OON) provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the emergency ambulance transportation (A0429) and ground mileage 
(A0425) provided on September 1, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that the 
enrollee was released at the time of request for transport, and you would like this claim to be reconsidered for 
coverage. The Plan denied your request. The Plan says that this claim is upheld because the place of treatment 
code billed on the claim image shows the enrollee was treated during an inpatient hospital stay. 
 
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 has not provided any evidence to indicate that the enrollee was 
registered as inpatient on the billed date of service. The Plan also has not forwarded any rationale as to why this 
ambulance service is not reimbursable. Therefore, we decided that the Plan has to pay for the emergency 
ambulance transportation (A0429) and ground mileage (A0425) provided on September 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gym equipment purchased on May 5, 2021. 
 
You asked the Plan to pay for the gym equipment. You say that the item should be covered. The Plan denied 
your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Additionally, 
your wellness allowance applies to gym memberships and not equipment. Therefore, we decided that the Plan 
does not have to pay for the gym equipment purchased on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on May 17, 
2021. 
 
You asked the Plan to pay for the moderate sedation services (99153). You say that the claim should be 
reviewed and reconsidered for payment. The Plan denied your request. The Plan says procedure codes 36245 
has been overturned. The Plan also says that CPT code 99153 may not be paid if furnished to a hospital 
inpatients or patients in a hospital outpatient department. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services (99153) have not 
been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) 
provided on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on September 3, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 lab tests 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 laboratory testing provided on September 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement (97597 and 97598) provided on May 11, 
2021. 
  You asked the Plan to pay for the debridement (97597 and 97598). You say that the rendering physician 
depends on the hospital staff to verify eligibility and obtain proper authorization. You say that the physician 
provided medically necessary services to the member in good faith and payment should be processed at the 
maximum allowed amount. 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 codes 
97597 and 97598 are column II codes to column I code 11104. 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 debridement (97597 and 97598) provided 
on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on May 17, 2021. 
 
You asked the Plan to pay for lab testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 lab testing 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 laboratory testing provided on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 4, 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. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (99100) provided on June 30, 2021. 
 
You asked the Plan to pay for the anesthesia (99100). You say that medical records and the Waiver of Liability 
are attached. You say that you request the records to be reviewed and the claim reprocessed for payment. The 
Plan denied your request. The Plan says procedure codes 01402, 64447 and 76942 have been overturned. The 
Plan also says that CPT code 99100 remains denied as bundled services are not eligible for separate payment. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia (99100) have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia (99100) provided on June 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrodesis (22614), posterior segmental instrumentation 
(22842), Microsurgical techniques (69990), and insertion of interbody biomechanical device (22853), provided 
on July 16, 2021. 
 
You asked the Plan to pay for the surgery. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services were obtained through a provider who has opted out of Medicare.  
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
arthrodesis (22614), posterior segmental instrumentation (22842), Microsurgical techniques (69990), and 
insertion of interbody biomechanical device (22853), provided on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on July 23, 2021. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 lab tests 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 laboratory testing provided on July 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on January 26, 
2021. 
 
You asked the Plan to pay for a shoulder-arm orthosis. You say that the item at issue was 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. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the medical records provided do not discuss the item at issue. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment provided from November 29, 2021, 
through December 6, 2021. 
 
 You asked the Plan to pay for the acupuncture treatment. You say that according to Medicare guidelines 
acupuncture is a covered benefit under the diagnosis of low back pain and the codes billed were to report low 
back pain. The Plan denied your request. The Plan says this provider is not supervised by any physician, PA, or 
NP/CNS. 
 
The Plan must follow Medicare rules. The rules say that these treatments may be provided 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. Auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist. 
 
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 acupuncture treatment. Our reviewer 
says that the acupuncture treatment does not meet the Medicare coverage criteria. Our physician reviewer 
found that based on the medical records provided there is no documentation that the acupuncture treatment at 
issue in this appeal meets the Medicare coverage criteria. The provided records do not document that the 
acupuncturist in this case was under the appropriate level of supervision of a physician, PA, or NP/CNS as 
required by regulations at 42 CFR  410.26 and 410.27. 
 
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 acupuncture treatment have not been met. Therefore, we decided that the 
Plan does not have to pay for acupuncture treatment provided from November 29, 2021, through 
December 6, 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 would like the inpatient admission to be 
reconsidered. The Plan denied your request. The Plan says this request 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 the enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. Our 
reviewer found that it is unlikely that the enrollee will make a significant functional improvement in the 
predicted 14 days of IRF stay. At the current level of function, the enrollee's rehabilitation can be safely 
provided at a lower intensity and alternate setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on September 30, 2021. 
 
You asked the Plan to pay for the drug testing. You say that this was medically necessary testing. The Plan 
denied your request. The Plan says that the rules indicate it is not medically necessary to test for the number of 
drugs included in this panel. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the drug testing by a contract provider. The file does not show that the plan 
provided notice that the drug testing would not be covered. Under Medicare rules, this means the drug testing is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the drug testing provided 
on September 30, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 2, 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. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on April 2, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous positive airway pressure (CPAP) device provided on 
September 9, 2021. 
 
You asked the Plan to pay for the CPAP device. You say that you would like reconsideration because you were 
told this equipment would be covered. The Plan denied your request. The Plan says that CPT code 99070 has a 
status indicator of B. 
 
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. Specifically, the Plan has not forwarded sufficient evidence to indicate why this 
payment was denied. Of note, the record suggests that the Plan assigned the non-covered code to this durable 
medical equipment. It is not appropriate to deny the CPT code that was applied by the Plan using the Physician 
Fee Schedule bundling rules. There is no further information in the record to show why this equipment is not 
reimbursable. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the 
Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has 
to pay for the continuous positive airway pressure (CPAP) device provided on September 9, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the soft tissue of the 
neck (70490) provided on September 8, 2021. 
 
You asked the Plan to pay for a CT scan of the soft tissue of the neck. You say that the provided records 
substantiate the service at issue. The Plan denied your request. The Plan says rules for payment have not been 
met because the service at issue is included in another billed code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70490 
is a column II code to column I code 70491. A modifier to bypass the edit is not appropriate for the specific 
edit at issue in this case. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for a computed tomography (CT) scan of the soft tissue of the 
neck (70490) provided on September 8, 2021.