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

 
We decided that the Plan does not have to pay for the laboratory services (80307 and G0483) provided May 2, 
2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
The medical records provided do not include laboratory results for the Healthcare Common Procedure Coding 
System (HCPCS) and CPT billed. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (80307 and G0483) provided May 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29581 rendered on March 16, 2023. 
 
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 does not meet coding standards. 
 
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 29581 is ""Application of multi-layer compression 
system; leg (below knee), including ankle and foot." 
 
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 that the medical record does not 
include documentation of compression application. A bilateral lower extremity arterial doppler and venous duplex ultasound procedures were performed on date of service March 16, 2023.  In this case, CPT 29581 
cannot be verified. 
 
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 procedure code 29581 rendered on March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634-59 provided August 11, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered 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 87798 is a column II code to column I code 87634; however, 87798 
was billed with a modifier.  
 
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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The laboratory report does not include documentation to support 
rationale for separate billing. CPT 87798 represents infectious agent detection, each organism amplified probe 
technique, which would include respiratory syncytial virus, amplified probe technique. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 87634-59 provided August 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 57 units of procedure code 00630 rendered on January 17, 
2023. 
 
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 records do not support the billed anesthesia time of 57 minutes. 
 
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 00630 is "Anesthesia for procedures in lumbar region; 
not otherwise specified." 
 
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. Our reviewer found that based on Medicare coding and payment standards, the 
anesthesia service reported (code 00630) is inconsistent with the surgical procedure(s) reported by the surgeon 
and/or the facility. CPT 01941 describes anesthesia for percutaneous image-guided neuromodulation or 
intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord (5 Base units). This CPT 
code appears to be appropriate. In this case, the medical records submitted with the appeal do not support the 
correct CPT code nor the correct total units billed on the original claim form. 
 
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 57 units of procedure code 00630 rendered on January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307 and G0483) provided March 
7, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered 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. 
 
The services are not supported by the records. The Plan states the submitted medical records do include a 
physician order; however, the medical records do not include laboratory results for the codes G0483 and 
80307. Based on this information, we decided that Medicare rules for coverage of the laboratory services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (80307 and 
G0483) provided March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
August 1, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
The record does not contain a valid and current physician order or relevant medical records which support 
medical necessity for the supplies provided in this case. There are no orders documented in the medical records 
for a Continuous Glucose Monitor (CGM) device or supplies. The records received do not indicate the enrollee 
has been seen every six months to document adherence to the enrollee's CGM regimen and diabetes treatment 
plan. 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 continuous glucose monitor (CGM) 
(A4239) provided on August 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve teriparatide. 
 
You asked the Plan to pre-approve the medication. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve teriparatide.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections.  
You asked the Plan to pre-approve Botox. You say that Botox is medically necessary. The Plan denied your 
request. The Plan says a trial of Myrbetriq is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Botox. Our reviewer says that Botox is 
not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drug or 
any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81225, 81226, 81227, 81240, 81241, 
81328) provided September 6, 2023. 
 You asked the Plan to pay for the laboratory services. You say that the claim should be paid. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
There is a more appropriate lab panel Current Procedural Terminology (CPT) code, 81479, that should be 
billed when one or more CPT codes are included in the same panel. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (81225, 81226, 81227, 81240, 81241, 81328) provided 
September 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for procedures on the peripheral nerves and 
ganglia (01992) provided on December 13, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the anesthesia services. You say that please review the attached documentation 
and reconsider reprocessing the certified registered nurse anesthetist claim for payment. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item/service at issue. Also, the claim was billed with 
diagnosis codes M54.16 and M54.50, which are not listed in Local Coverage Article A57361, as diagnosis 
codes that support medical necessity. 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 anesthesia for procedures on 
the peripheral nerves and ganglia (01992) provided on December 13, 2022, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on September 1, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
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 the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on September 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 11, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services are not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned PC/TC indicator 9. This means that the concept of a professional/technical component does 
not apply. As such, it is inappropriate to bill these codes with modifier 26 in this case. 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 11, 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the records do not show the enrollee has complex rehabilitation 
needs that require frequent evaluation by a rehabilitation physician and an intensive team. The Plan says 
services may be provided at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
records support 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. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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: 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 suffers from Parkinson's which is in 
exacerbation. You also say that the enrollee has suffered from falls and would benefit from a stay in acute 
inpatient rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF 
services requested 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for back pain. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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. There is not a reasonable expectation that the 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extremity veins (93970) provided on July 
20, 2023. 
 
You asked the Plan to pay for the duplex scan. You say that the service was billed correctly and should be paid. 
The Plan denied your request. The Plan says there is a more appropriate CPT code that should be used to bill 
for the service provided. 
 
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 93970 is duplex scan of extremity veins including 
responses to compression and other maneuvers; complete bilateral study. 
 
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 duplex scan. Our reviewer found the procedure report 
describes a limited duplex scan and a more specific code should be reported for the service. 
 
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 duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pay for the duplex scan of extremity veins (93970) provided on July 20, 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 the enrollee is extremely motivated to return home 
safely but feels they need additional therapy to regain their strength prior to returning home. The Plan denied 
your request. The Plan says admission to the IRF 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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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.