Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria, and their ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says the enrollee can safely receive the care they need in the 
hospital setting.  
 
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 that there are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and COVID-19 testing provided on August 11, 
2022, by an out-of-network (OON) provider.  
 You asked the Plan to pay for the office visit and COVID-19 testing. You say that all COVID related services 
should be covered. The Plan denied your request. The Plan says that the original decision to deny payment for 
service was correct. 
 
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 an office visit and COVID-19 testing provided on 
August 11, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on June 
01, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the provider did not 
remove your feeding tube on this date, and you feel you should not have to pay for this visit. 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 $35 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner 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. Therefore, we decided that the Plan does not have to waive the copayment 
for the specialist office visit provided on June 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
22, 2022. 

 You asked the Plan to pay for procedure code 99100. You say that this claim was denied by the Plan in error 
due to a provider registry issue. The Plan denied your request. The Plan says procedure code 99100 is 
considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87798, 87653 and 87641 billed for 
date of service July 17, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87798, 87653 and 87641. You say that these services 
were necessary and were reported appropriately. The Plan denied your request. The Plan says these services are 
not supported for separate billing or 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, we have confirmed that codes 87481, 87798, 87653 and 87641 are column II codes to column I 
code 87801; however, 87481, 87798, 87653 and 87641 were each 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 procedure codes 87481, 87798, 87653 and 87641. Our 
reviewer says that the use of the 59 modifier is not supported with these codes. Our reviewer found the records 
in this case document one urine specimen was obtained for date in question and analyzed for a urinary tract 
infection (UTI) panel. The records do not clarify that codes 87481, 87798, 87653 and 87641 were separate, 
distinct or independent services from the codes that were approved. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87798, 87653 and 87641 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87481, 87798, 87653 and 87641 billed for 
date of service July 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance services (A0428, A0428, 
A0382) to a physician's office. 
 
You asked the Plan to pre-approve non-emergency ambulance services to a physician's office. You say that the 
services are medically necessary. The Plan denied your request. The Plan says Medicare does not cover 
ambulance rides to doctors office visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pre-approve are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pre-approve non-emergency ambulance services (A0428, 
A0428, A0382) to a physician's office.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 for date of service May 15, 2023. 
 
You asked the Plan to pay for procedure code 87481. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. 
 
We find that CPT code 87481 is not supported in the medical record. Specifically, no medical records were 
provided to support the services billed. Without medical records, code 87481 cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of procedure code 87481 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 87481 for date of service May 15, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95940 provided on May 24, 2023. 
 
You asked the Plan to pay for procedure code 95940. You say that the medical records support the billing of 
procedure code 95940 with the XP modifier. The Plan denied your request. The Plan says the medical records 
do not support the billing of procedure code 95940 with the XP modifier. 
 
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 95940 is a column II code to column I code 95955; however, 95940 
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 procedure code 95940. Our reviewer says that the medical 
records do not support the billing of procedure code 95940 with the XP modifier. Our reviewer found provided 
records in this case do not include any documentation to clarify that CPT code 95940 was distinct from CPT 
code 95955. Records document a hematoma evacuation and posterior spinal decompression of L1 - L3 during a 
one time period from 0630 to 0919 on May 24, 2023, with an intraoperative electroencephalogram (EEG), 
evoked potentials, electromyography and neuromuscular junction testing but no evidence that CPT code 95940 
(continuous intraoperative neurophysiology monitoring) was distinct from CPT code 95955 (EEG).  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95940 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95940 provided on May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve center mount power elevating leg rest/platform 
identified with code E1012 and electronic connection between wheelchair controller and two or more power 
seating system motors identified with code E2311. 
 
You asked the Plan to pre-approve center mount power elevating leg rest/platform and electronic connection 
between wheelchair controller and two or more power seating system motors. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are only covered for certain 
indications. 
 
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 center mount power elevating leg 
rest/platform and electronic connection between wheelchair controller and two or more power seating system 
motors. Our reviewer says that the documentation does not support that the requested items are medically 
reasonable or necessary. Our physician reviewer found the enrollee has spasticity and congestive heart failure. 
The enrollee is independent in feeding, upper body dressing. There is no evidence of lower extremity edema 
per the May 9, 2023, physician progress note. There is no evidence of knee flexion contracture. The enrollee 
does not have a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion 
at the knee; or significant edema of the lower extremities that requires an elevating legrest; or meets the criteria 
for and has a reclining back on the wheelchair. Only one power option was approved (power tilt). There is not a 
medical need to control any power options through the joystick as the patient is independent in feeding and 
dressing therefore his functional ability should be able to control any power options through their switches. 
Therefore, the enrollee does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of center mount power elevating leg rest/platform and electronic connection 
between wheelchair controller and two or more power seating system motors have not been met. Therefore, we 
decided that the Plan does not have to pre-approve center mount power elevating leg rest/platform identified 
with code E1012 and electronic connection between wheelchair controller and two or more power seating 
system motors identified with code E2311.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87481 and 87798 provided 
April 25, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration and full 
for the test performed. The Plan denied your request. The Plan says no records have been received to support 
the services billed. 
 
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 service have been met. 
additional records were requested from the provider to support the services. The records show that the Plan 
made multiple attempts to obtain the needed records without success. Therefore, we decided that the Plan does 
not have to pay for the laboratory services coded as 87481 and 87798 provided April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 4, 2023, billed with 
multiple codes including 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported as billed. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 4, 2023, billed with multiple codes including 81433.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right lower extremity sclerotherapy.  
 
You asked the Plan to pre-approve right lower extremity sclerotherapy. You say that this is medically necessary 
for the enrollee. The Plan denied your request. The Plan says saphenous reflux is still present and therefore 
sclerotherapy is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are at least 4 millimeters (mm) in diameter and if the patient remains symptomatic after a six-week trial of 
conservative therapy. 
 
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 right lower extremity sclerotherapy. 
Our reviewer says that the request for right lower extremity sclerotherapy is not medically necessary. Our 
physician reviewer found it is not possible to attribute the patients leg symptoms to varicose veins in the absence of an assessment of lower extremity arterial perfusion. In this case, no assessment of lower extremity 
arterial perfusion is documented. Additionally, it is not documented that the enrollee is having significant 
symptoms despite both great and small saphenous vein ablation that is resistant to conservative treatment such 
as compression stockings. The enrollee has not been evaluated a sufficient time following his ablations to make 
this determination. Therefore, the reviewer found that the request for right lower extremity sclerotherapy is not 
medically reasonable or 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 right lower extremity sclerotherapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve right lower extremity sclerotherapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87070 billed for date of service January 18, 
2023. 
 
You asked the Plan to pay for procedure code 87070. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says payment for code 87070 is bundled into 
payment for code 87086. 
 
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 87070 
is a column II code to column I code 87086. 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 87070 billed for date of service January 18, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
16, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the Plan incorrectly denied your claim due 
to a provider registry issue. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
21, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the Plan is processing your claims 
incorrectly based on the provider roster information. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 10, 2023, billed with 
multiple codes including 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 10, 2023, billed with multiple codes including 81433.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
you would like the documentation for the K0861 base, and all recommended components needed to meet the 
enrollee's current medical, mobility, and functional needs to be reconsidered. The Plan denied your request. 
The Plan says although there are three approved power options on this wheelchair (tilt, recline and elevating 
leg rests), there is not a medical need to control these power options through the joystick.  
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee's right upper extremity 
strength should be sufficient to control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), expandable controller (E2377).