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

 
We decided that the Plan does not have to pay for lab services billed with code 87801 provided on April 13, 
2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services billed with code 87801 provided on April 13, 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 requires medical oversight and can 
tolerate 3 hours of therapy per day. You say that the enrollee requires a higher level of care that a skilled 
nursing facility cannot provide. The Plan denied your request. The Plan says an IRF admission 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee orthosis identified with code L1852. 
 
You asked the Plan to pre-approve a knee orthosis identified with code L1852. You say that you are not able to 
get around and the knee brace would allow you to get around more mobile. The Plan denied your request. The 
Plan says that the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that knee orthoses are 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 a knee orthosis identified with code 
L1852. Our reviewer says that the documentation supports that the requested item is medically reasonable and 
necessary. Our physician reviewer found you have chronic, progressive right knee osteoarthritis (OA) 
(tricompartmental, confirmed on x-ray) with increasing pain and difficulty ambulating. The documentation 
shows that you are ambulatory and have a knee instability due to a condition specified in the Group 4 ICD-10 
Codes in the LCD-related Policy Article. The knee instability is documented by examination of the beneficiary 
and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). In 
addition, objective descriptions of joint laxity inherent to knee OA necessarily must include tests for internal, 
cartilaginous knee compartment damage which cause the knee to be unstable when walking, and those exam 
findings are sufficient on their own to justify coverage. Therefore, you do meet criteria for the requested item. 
 
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 knee orthosis identified with code L1852 have been met. Therefore, we 
decided that the Plan has to pre-approve a knee orthosis identified with code L1852.  
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81518) billed for date of service May 5, 
2023. 
 You asked the Plan to pay for genetic testing. You say that the DOS must be the date the test was performed 
because the test at issue was a molecular pathology test performed by a laboratory other than a blood bank or 
center. The Plan denied your request. The Plan says the DOS reported on the claim is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. If a specimen is collected over a period that spans two calendar days, then the DOS 
must be the date the collection ended. For a molecular pathology test performed by a laboratory other than a 
blood bank or center, or a test designated by Medicare as an ADLT, the DOS must be the date the test was 
performed only if the criteria listed in the Medicare rules section of this letter are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the case record does not include documentation 
that the test was performed following a hospital outpatients discharge from the hospital outpatient department 
or that the specimen was collected from a hospital outpatient during an encounter. An exception to the DOS 
rules is not supported. Therefore, we decided that the Plan does not have to pay for genetic testing (81518) 
billed for date of service May 5, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve taxi transport services to a doctors office. 
 
You asked the Plan to pre-approve taxi transport. You say that the services are medically necessary. The Plan 
denied your request. The Plan says transportation by taxi is not covered under any condition. 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when it is a medical emergency. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve taxi transport services to a doctors office.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 15, 2023, billed with 
evaluation and management (EM) code 99308.  
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the benefit for this service is included in the 
payment of another service. 
 
The Plan must follow Medicare rules. Medicare rules say that Physicians in the same group practice who are in 
the same specialty must bill and be paid as though they were a single physician. Only one evaluation and 
management service may be reported unless the evaluation and management services are for unrelated problems. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. We find that evaluation and management 
code 99443 was also billed and paid for this same physician group on the same date of service. Therefore, we 
decided that the Plan does not have to pay for practitioner services provided on May 15, 2023, billed with 
evaluation and management (EM) code 99308.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate.

You asked the Plan to pre-approve transurethral waterjet ablation of the prostate. You say that it is medically necessary. The Plan denied your request. The Plan says although the enrollee would meet general medical criteria for aqua ablation it is specifically excluded from coverage for beneficiaries 81 years and old.

The Plan must follow Medicare rules. Medicare rules say that transurethral waterjet ablation of the prostate may be covered if certain criteria are met.

We looked at the file and Medicare rules. The enrollee is more than 80 years old. Based on this information, we decided that Medicare rules for coverage of transurethral waterjet ablation of the prostate have not been met. Therefore, we decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided March 
3, 2023. 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that please review and reprocess the 
claim. The Plan denied your request. The Plan says under Medicare guidelines, this request is not a covered 
benefit. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The enrollee does not have a diagnosis of psoriasis Based on this 
information, we decided that Medicare rules for coverage of the ultraviolet light therapy system have not been 
met. Therefore, we decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) 
provided March 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that the doctor did more work than the Plan 
approved. You say that you should not have to pay for this. The Plan denied your request. The Plan says your 
annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service June 8, 2023. Therefore, we 
decided that the Plan does not have to pay any additional charges for dental services provided on June 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided March 4, 
2023, to March 23, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you have outlined how this 
enrollee's medical necessity actually meets the guidelines that qualify for coverage. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
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 March 4, 2023, to March 23, 2023.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone and alcohol and/or drug 
screening provided from May 4, 2023, to May 11, 2023.  
 
You asked the Plan to pay for the medication assisted treatment, methadone and alcohol and/or drug screening. 
You say that you are an approved Medicare facility as you participate with Medicare and Medicare processes 
the claims for this code. You say you have been a Substance Abuse and Mental Health Services Administration 
(SAMHSA) certified listed provider since 2004. The Plan denied your request. The Plan says that the charge 
for the drug and its administration must be billed by the Medicare-enrolled Opioid Treatment Program. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for medication assisted 
treatment, methadone and alcohol and/or drug screening provided from May 4, 2023, to May 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27506 rendered on November 11, 2022. 
 
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 Current Procedural Terminology (CPT) code remains 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 27506 is "Open treatment of femoral shaft fracture, with 
or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking 
screws." 
 
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 documentation does not 
support that CPT 27506 was rendered in this case. 
 
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 27506 rendered on November 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Zoledronic Acid. 
 
You asked the Plan to pre-approve the tier exception. You say that the tier exception is necessary. The Plan 
denied your request. The Plan says a tier exception is not available for this drugs. 
 
The Plan must follow Medicare rules. Medicare rules state that tiering exceptions cannot apply to Part B drugs. 
Tiering exceptions are only applicable to Part D drugs.  
 
We looked at the file and Medicare rules. The drug(s) you are requesting is considered a Part B drug. As a 
result, no tiering exceptions can be made. Therefore, we decided that the Plan does not have to pre-approve a 
tier exception for Zoledronic Acid.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services coded as 0018U an 0245U provided on 
September 15, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this test should be considered a medically 
necessity and was requested by the referring physician to aid in the clinical management of this enrollee. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. Payment for 
code 0245U is bundled into payment for code 0018U. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Additionally, the test 
has not been cleared or approved by the FDA and is not a companion diagnostic for any therapy. Medicare 
rules say that providers must report services correctly. Providers must report services with the appropriate CPT 
code. We have confirmed that code 0245U is a column II code to column I code 0018U. This claim has not 
been billed with an appropriate modifier to bypass the edit. Therefore, we decided that the Plan does not have 
to pay for laboratory services coded as 0018U an 0245U provided on September 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483 and 80307) provided February 15, 
2023. 
 
You asked the Plan to pay for the drug testing. 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. 
 
Review of the file shows that both codes G0483 and 80307 were billed on the same date of service and have 
been performed by the same and/or different provider on the same date of service. Medicare rules state that for 
each code, "only one code from the code range may be reported per date of service." Based on this information, 
we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the drug testing (G0483 and 80307) provided February 15, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug test(s), 15-21 drug class(es) (G0482) provided December 2, 
2022. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the documentation submitted did not include a valid physician order/lab requisition 
or medical records; therefore, the billed code cannot be verified. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the documentation submitted did actually include a 
valid physician order/lab requisition or medical record. Therefore, we decided that the Plan has to pay for the 
drug test(s), 15-21 drug class(es) (G0482) provided December 2, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on May 24, 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 Current Procedural Terminology (CPT) code 99152-59 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that 
there is no documentation to support the 99152 with a 59 modifier as all the observations of the enrollee's vitals 
occurred during the procedure.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99152) rendered on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on May 1, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you have not reached your dental 
maximum. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
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 the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided on May 1, 2023.