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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from June 3, 
2023, to July 2, 2023. 
 You asked the Plan to pay for SNF care. You say that services should be covered under the Medicare Act. The 
Plan denied your request. The Plan says the enrollee did not meet the criteria for the SNF stay. 
 
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 pay for 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 the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
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 pay for skilled nursing facility (SNF) care provided from June 3, 2023, to July 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308 for date of service July 16, 2023. 
 
You asked the Plan to pay for procedure code 99308. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 36589 
provided on the same date of service. We find that the service at issue may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99308 
for date of service July 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided May 5, 
2023, to May 24, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that please see attached documents 
and reprocess the claim. The Plan denied your request. The Plan says this is considered not medically necessary 
and not covered by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided May 5, 2023, to May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded as 01656 billed for date of 
service June 7, 2023. 
 
You asked the Plan to pay for 01656. You say that 01656 should be paid as billed because it is supported in the 
documentation and was a separate procedure from any other billed on the same date. The Plan denied your 
request. The Plan says 01656 is denied because it was billed the same day by the same provider as anesthesia 
code 01270 with no modifier to distinguish it as a separate surgical encounter or session. 
 The Plan must follow Medicare rules. Medicare rules say that anesthesia services associated with multiple 
bilateral surgeries are billed by reporting the anesthesia procedure with the highest base unit value with the 
multiple procedure modifier -51. Payment is determined based on the base unit of the anesthesia procedure 
with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures. 
 
We looked at the file and Medicare rules. In this case, we confirmed that both the anesthesia code in question, 
01656, and 01270, billed by the same provider, were reported for the same exact time period on the same date 
of service. We confirmed that modifier -51 was not appended to either code to indicate multiple procedures 
were performed in the same session. Payment for anesthesia associated with multiple procedures is determined 
based on the base unit of the anesthesia procedure with the highest base unit value and actual anesthesia time 
for the multiple procedures. Only the time units of the anesthesia procedure with the lower base unit would be 
eligible for payment. In this case, the time units for both 01656 and 01270 were reported for the exact same 
time period, so no separate payment would be made for the second code. Based on this information, we decided 
that Medicare rules for coverage of 01656 have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia services coded as 01656 billed for date of service June 7, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93306 billed for date of service June 9, 2023. 
 You asked the Plan to pay for procedure code 93306. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 93306 is bundled into payment for code 
33361. 
 
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 93306 
is a column II code to column I code 33361 which was paid on another claim. 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 procedure code 93306 billed for 
date of service June 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88334 billed for July 5, 2023. 
 
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 88334 is 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 88334 is pathology consultation during surgery; cytologic 
examination (eg, touch prep, squash prep), each additional site (List separately in addition to code for primary 
procedure). 
 
We find that CPT code 88334 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 88334 billed for July 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652, 
E0656, E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers available. 
 
The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a 
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating 
practitioner to avoid an adverse medical outcome.  
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that a Flexitouch brand was recommended by the physician. However, there is a lack of documentation 
indicating why this specific brand is necessary to avoid an adverse medical outcome. Therefore, the requested 
Flexitouch segmented, calibrated gradient pneumatic compression device and components (E0652, E0656, 
E0667) cannot be considered medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Flexitouch pneumatic compression device (E0652, E0656, E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MagnetOs allograft (20930). 
 
You asked the Plan to pre-approve a MagnetOs allograft. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MagnetOs allograft. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that shows the 
requested allograft to be an effective and/or safe treatment for the enrollee's pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MagnetOs allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MagnetOs allograft (20930).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued skilled nursing facility (SNF) care provided 
from March 30, 2023, to April 28, 2023. 
 You asked the Plan to pay for the continued SNF care. You say that the services should be covered under the 
Medicare Act. The Plan denied your request. The Plan says the enrollee did not meet the criteria for the 
continued SNF care. 
 
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 pay for 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 the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
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 pay for the continued skilled nursing facility (SNF) care provided from March 30, 2023, to April 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
January 13, 2023, and billed with codes 87500, 87641, 87798, G0452, 87491, 87496, 87529, 87532, 87563, 
87591, 87661, 87481, 87651, and 87653. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says per Local Coverage Article (LCA) A58726, this type of testing must be 
billed as a single unit of service with a single code. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on January 13, 2023, 
and billed with codes 87500, 87641, 87798, G0452, 87491, 87496, 87529, 87532, 87563, 87591, 87661, 87481, 
87651, and 87653.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pharmacogenetic testing (81479) provided on June 27, 
2023. 
 
You asked the Plan to pre-approve the pharmacogenetic testing. You say that this test 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 for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met.  
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 pharmacogenetic testing have been 
met. No clinical records were provided to support that this test was medically necessary. Only lab results were 
submitted. Therefore, we decided that the Plan does not have to pre-approve pharmacogenetic testing (81479) 
provided on June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81479) provided on July 4, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this testing was medically necessary and 
appropriate. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services (81479) provided on July 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92004), a 
determination of refractive state (92015) and an unlisted special service (99199) provided on August 30, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination (92004), a determination of 
refractive state (92015) and an unlisted special service (99199). You say that you do not feel this should be 
paid and your benefits should be restored. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 $20 
copayment for routine vision care. 
 
You have been asked to pay a $20 copayment for a medical eye examination (92004), a determination of refractive state (92015) and an unlisted special service (99199). This item/service falls within the routine vision 
care 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 waive the copayment for a medical eye examination 
(92004), a determination of refractive state (92015) and an unlisted special service (99199) provided on August 
30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99152 and 99153 for date of service July 5, 
2023. 
 
You asked the Plan to pay for procedure codes 99152 and 99153. You say that you disagree with the Plan's 
denial. 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. 
 
In this case, the CPT Code Manual definition of code 99152 and 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; initial 15 minutes of intraservice 
time, patient age 5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted 
did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level 
of consciousness and physiological status; therefore, this code cannot be verified. 
 
Procedure code 99153 has a Professional Component/Technical Component of 3. This means this code is a 
technical component only. This indicator identifies stand-alone codes that describe the technical component 
(i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes 
the professional component of the diagnostic tests only. An example of a technical component code is 93005, 
Electrocardiogram, tracing only, without interpretation and report. It also identifies codes that are covered only 
as diagnostic tests and therefore do not have a related professional code. Modifiers 26 and TC cannot be used 
with these codes. The total RVUs for technical component only codes include values for practice expense and 
malpractice expense only. This means code 99153 is not payable as billed. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 99152 and 99153 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99152 and 
99153 for date of service July 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11042 billed for January 9, 2023. 
 
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 service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 28122 
provided on November 9, 2022. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 11042 billed for 
January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interrogation device evaluation provided on July 12, 2023. 
 
You asked the Plan to pay for interrogation device evaluation. You say that the services should be covered. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for interrogation device 
evaluation provided on July 12, 2023.