Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for ultrasound guidance coded as 76937 performed on April 11, 2023. 
 
You asked the Plan to pay for 76937. You say that code 76937 should be covered as billed because its use is 
supported in the documentation.  The Plan denied your request. The Plan says that code 76937 is an add on 
code billed with an incorrect primary procedure 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 76937 is ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle 
entry, with permanent recording and reporting. 
 
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 76937. Our reviewer says that code 76937 is supported in the 
documentation. Our reviewer found that the primary procedure code reported, CPT 61645, does not include 
ultrasound guidance per CPT code description "fluoroscopic guidance."  After review of procedure code 
guidelines and Medicare guidelines, our reviewer was unable to confirm 76937 cannot be reported with CPT 
61645. When ultrasound guidance is used for assistance with vascular access, as seen in the CPT description 
above, it must include all the following: 
 -Ultrasound must be used to evaluate potential access sites. 
 -The dictated report must include documentation of the patency of the vein selected for entry. Examples: 
Documentation such as patent, narrowed, or tortuous vein(s). 
 -Ultrasound must be used for real-time visualization of vascular entry. 
 -It is not appropriate to code 76937 if the vessel is seen by ultrasound and marked, but ultrasound is not used 
to guide the needle entry. 
 -There must be documentation of the localization process in the medical record. 
 -There must be permanent recordings (image(s)) of the chosen vein. 
 -If the interpreting physician does not include documentation of permanent image recording in the procedure 
report, copies of images must be provided for each account coded or audited. 
 
The documentation provided supports that this criteria has been met. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 76937 have been met. Therefore, we decided that the Plan has to pay for 
ultrasound guidance coded as 76937 performed on April 11, 2023.  
 
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: 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 the enrollee meets IRF criteria and is able to tolerate 
three hours of therapy. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF 
services you are requesting do not meet the requirements for approval. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (Q5001, G0299, 3CC31) provided on 
January 5, 2023 to January 26, 2023. 
 
You asked the Plan to pay for home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that codes  is not supported in the medical record. Specifically, the dates of service billed do not match 
the 30-day period of care listed in the records. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pay 
for home health services (Q5001, G0299, 3CC31) provided on January 5, 2023 to January 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483) provided on March 9, 2023.  
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Review of the file shows that the medical 
records do not contain an order that specifically list what test(s) are to be performed in the custom panel. Based 
on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing (G0483) provided on March 9, 2023.
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 with the exercises of good therapists and your effort, 
you will be able to recover and not have to return to the hospital again. The Plan denied your request. The Plan 
says your condition does not require the specialized, intensive rehabilitative services available in an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable, and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), polycarbonate lenses (V2784), anti-
reflective coating (V2750), deluxe lenses (V2702) and progressive lenses (V2781) provided on April 15, 2023. 
 
You asked the Plan to pay for frames (V2020), polycarbonate lenses (V2784), anti-reflective coating (V2750), 
deluxe lenses (V2702) and progressive lenses (V2781). You say that you would like the Plan to review your 
account. The Plan denied your request. The Plan says that based on the information, the Plan determined that 
they would maintain their original decision to not pay additionally for services from the rendering provider. 
 
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 up to $300 towards the purchase and fitting of eyeglasses and pair of lenses. You are 
responsible for any amount over the $300 retail price. 
 
We looked at the file and the Plan's rules. The Plan rules say that you have a $300 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). The Plan rules also say you 
are responsible for any amount of the $300 retail price. The record shows the Plan applied the $300 benefit, 
then gave you a 20% discount on the balance of $14, which left you with a balance of $11.20. Based on this 
information, we decided that the Plan's rules for coverage of frames (V2020), polycarbonate lenses (V2784), 
anti-reflective coating (V2750), deluxe lenses (V2702) and progressive lenses (V2781) have not been met. 
Therefore, we decided that the Plan does not have to pay for frames (V2020), polycarbonate lenses (V2784), 
anti-reflective coating (V2750), deluxe lenses (V2702) and progressive lenses (V2781) provided on April 15, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a breast cancer screening/mammogram provided on  
March 20, 2023. 
 
You asked the Plan to pay for the breast cancer screening/mammogram. The Plan denied your request. The 
Plan says the member had the same service on August 25, 2022 that was paid by the health Plan. 
 
The Plan contract covers one screening mammogram every 12 months for women age 40 and older. 
 
 
 
 
 
 
 
 
 
  
We looked at the file and the Plans rules. The file shows that the enrollee exceeded the Plan benefit limit of 
one screening mammogram every 12 months. Based on this information, we decided that the Plans rules for 
coverage of the breast cancer screening/mammogram have not been met. Therefore, we decided that the Plan 
does not have to pay for a breast cancer screening/mammogram provided on March 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a comprehensive periodontal evaluation 
and fillings (D2393, D2392, D0180) provided on March 15, 2023. 
 
You asked the Plan to waive the cost-sharing for the dental services. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay a $50 copayment for two fillings. This item/service falls within the dental services 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for dental exams was exhausted on the appealed claim with date of service March 15, 2023 
(D0180). Therefore, we decided that the Plan does not have to waive the cost-sharing for a comprehensive 
periodontal evaluation and fillings (D2393, D2392, D0180) provided on March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 
87801, billed for date of service January 19, 2023. 
 You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 87801. The Plan 
denied your request. The Plan says the claim is 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. In this case, we have confirmed that code 87150 
is a column II code to column I code 87500. We have also confirmed that codes 87481, 87641, 87653, and 
87798, are column II codes to column I code 87150. 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. 
 
We find that CPT code 87500 is not supported in the medical record. Specifically, the records provided do not 
confirmed the multiple organisms represented by code 87801. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481, 87641, 87653, 87798, and 87801 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 
87653, 87798, and 87801, billed for date of service January 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional intraoral x-ray (D0230) provided on February 
10, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 10, 2022. 
Therefore, we decided that the Plan does not have to pay for an additional intraoral x-ray (D0230) provided on 
February 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided March 13, 2023 to April 3, 
2023. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the providers are not eligible for Medicare payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for home health services provided March 
13, 2023 to April 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the screening mammography services 
provided on January 25, 2023. 
 
You asked the Plan to pay for the mammogram interpretation. You say that this was correctly billed with an 
outpatient POS code.  The Plan denied your request. The Plan says the POS code billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the PC of diagnostic testing should be reported in 
the same POS as the TC of the service. 
 
We looked at the file and Medicare rules. The claim was billed with POS code 23, for emergency room. The 
Plan has shown that the facility claim did not indicate that this imaging was done in the emergency room, and 
the records do not support this, either. As such, POS 23 is not supported. Based on this information, we decided that Medicare rules for coverage of the mammogram interpretation have not been met. Therefore, we decided 
that the Plan does not have to pay for the interpretation of the screening mammography services provided on 
January 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 5, 
2023, to January 7, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says inpatient admission was not medically 
necessary. 
 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 that based on the documentation provided, it was not expected that the enrollee 
would have required hospital services that would have likely crossed 2 midnights. 
 
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 the acute inpatient hospital care provided from January 5, 2023, to January 7, 
2023.
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 standard rehabilitation does not have the 
manpower to facilitate the enrollee's recovery in a healthy way. The Plan denied your request. The Plan says 
the enrollee does not meet the guidelines for care in an LTACH. 
 
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 the enrollee has a complicated post-operative course complicated by ascites 
requiring serial paracenteses. The enrollee is debilitated and unable to take part in meaningful rehabilitation. 
Overall, the enrollee is receiving the necessary care at the acute care hospital without any specific therapies 
they would receive at the LTACH that are not currently being offered. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need that level of care due to being laid up in a 
hospital bed for months. You say you would like to walk again without pain. The Plan denied your request. The 
Plan says the SNF services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. You 
do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.