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

 
We decided that the Plan has to pay for the services described by procedure code(s) 70498, 70496, and 0042T. 
We decided that the Plan does not have to pay for the services described by procedure code(s) 70450.  
 
You asked the Plan to pay for the imaging services coded as 70450, 70498, 70496, and 0042T performed on 
date of service May 9, 2023. You say that 70450, 70498, 70496, and 0042T should be covered as billed 
because they are supported in the record. The Plan says that 70450 is denied because payment for this service is 
bundled into payment for 70496. Codes 70498, 70496 and 0042T were handled as an original decision reopen 
for New and Material Evidence, therefore no appeal decision was made. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 70498, 70496, and 
0042T.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 70498, 70496, and 0042T.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
70450. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, we have confirmed that code 70450 is a column II code 
to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based 
on this information, we decided that Medicare rules for coverage of the services described by procedure code(s) 
70450 have not been met. Therefore, we decided that the Plan does not have to pay for the services described 
by procedure code(s) 70450. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on March 14, 
2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says this testing is not 
medically necessary. 
 
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 pay for the panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a urine 
culture and susceptibility studies. In addition, there is lack of support for the clinical utility of large multiplex 
polymerase chain reaction (PCR) urinary tract infection panel tests. 
 
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 panel have not been met. Therefore, we decided that the Plan does not have 
to pay for the urinary tract infection (UTI) panel provided on March 14, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the echocardiography services coded as 93318 performed on February 
27, 2023. 
 
You asked the Plan to pay for 93318. You say that 93318 should be covered because records support it was a 
distinct separate procedure. The Plan denied your request. The Plan says that 93318 is denied because payment 
for this code is bundled into payment for code 01926, which was billed on the same date of service. 
 
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 case file did not include proof that code 01926 was billed for date of service 
February 27, 2023, by the same provider who performed code 93318. Without documentation showing 01926 
was billed by the same provider for the same date of service, we cannot confirm whether the Plans rationale 
was correct in denying 93318. Therefore, we decided that the Plan has to pay for the echocardiography services 
coded as 93318 performed on February 27, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission based on medical necessity. The Plan denied your request. The Plan says 
the request for admission to an LTACH is being denied as not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee appears to be responding to current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility. There are no 
services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH would not be clinically advantageous at this time and completion of treatment 
at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service April 23, 
2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 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 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. 
 
 We find that CPT code 99233 is not supported in the medical record. The records show that the enrollee was 
stable, alert, and in no acute distress. Hemodialysis and labs were ordered. The documentation does not show 
that a high level of medical decision making was provided. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99233 billed for date of service April 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99225) provided on December 8, 2022 to 
December 9, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 CPT code 99225 is not supported in the medical record. Specifically, the medical records provided 
for review are not for the dates of service billed. The records provided are for December 7, 2022 and December 
10, 2022. Based on this information, we decided that Medicare rules for coverage of the physician services 
have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99225) 
provided on December 8, 2022 to December 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 23, 2023, billed 
with codes 81219, 81270 and 81338. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was 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 
February 23, 2023, billed with codes 81219, 81270 and 81338.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 29, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not payable. 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 81456 billed for date of service March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 15, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that this should be paid for. The Plan denied your 
request. The Plan says the records do not support the services billed. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the 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 provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service April 11, 2023. 
 
You asked the Plan to pay for code 99223. You say that the records support payment of this code. The Plan 
denied your request. The Plan says code 99223 cannot be supported for billed date of service April 11, 2023. 
The submitted medical records do include an evaluation and management note, but the note indicates that the 
perform date is April 10, 2023. This does not match the date of service billed. As a result, the exact date of 
service cannot be verified. 
 
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 99223 is Initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded.  
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 code 99223. Our reviewer says that code 99223 is not 
supported by the medical record. Our reviewer found the initial evaluation and management procedure report is 
not correctly documented, as result date documents "April 10, 2023 23:03 PDT; "Document Has Been 
Revised"; and handwritten "DOS 4/11/23 CPT 99223".  All procedures within the report documents April 10, 
2023.  Handwritten documentation on the procedure report does not include sufficient documentation to 
support date of service. When an error is made on a medical record documentation should include a corrected 
addendum with correct initials/signatures. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service April 11, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97530, 97112, and G0283 billed for October 
19, 2022, to October 20, 2022. 
 
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 codes 97530, 97112, and G0283 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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. The definition 
of code 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of 
movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing 
activities. The definition of code G0283 is electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care. 
 
We find that CPT codes 97530, 97112, and G0283 are not supported in the medical record. Specifically, the 
records do not support that 15 minutes of therapeutic activities with direct patient contact were performed to 
support code 97530. The records do not support that 15 minutes of neuromuscular reeducation of movement 
was performed to support code 97112. The records do not support that unattended electrical stimulation was 
performed to support code G0283. 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 codes 
97530, 97112, and G0283 billed for October 19, 2022, to October 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service November 
17, 2022, to December 16, 2022. You asked the Plan to pay for the billed services. You say that the NOA was submitted. The Plan denied your 
request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 20, 2022. The NOA was not received by the Plan until January 
11, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service November 17, 2022, to December 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0069 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code G0069. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not covered. 
 
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 G0069 has a Status Indicator of X on the Physician Fee Schedule. This means that procedure code G0069 is statutorily excluded. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0069 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code G0069 billed for date of service August 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination provided on May 24, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for eye exam. You say that you were told you could go to this provider and submit a 
claim for payment. The Plan denied your request. The Plan says this provider is out-of-network with the Plan 
and authorization was not obtained. 
 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 eye examination provided on May 24, 2023, by 
an out-of-network (OON) provider.   
 
Your complaint about receiving inaccurate information about coverage for this provider is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 3 additional PT visits. We decided that the Plan does not have to 
pre-approve 20 additional PT visits.  
 
You asked the Plan to pre-approve 23 additional physical therapy (PT) visits. You say that you are appealing 
the denial of 23 additional PT visits. The Plan says that the request is not medically necessary. 
 
We decided that the Plan has to pre-approve 3 additional PT visits.  
 
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 PT visits. Our reviewer says that the 
request is medically necessary. Our physician reviewer found you continue to be at high risk for falling and 
would benefit from continued physical therapy to address strength and balance deficits and transition 
completely to a home exercise program. The Plan initially approved 4 visits, and 3 additional sessions would be 
appropriate with a re-revaluation to assess for objective measurement of progress with continued physical 
therapy.  
 
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 PT visits have been met. Therefore, we decided that the Plan has to pre-
approve 3 additional PT visits.  
 
We also decided that the Plan does not have to pre-approve 20 additional PT visits. 
 
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 20 additional PT visits. Our reviewer 
says that the additional 20 sessions are not medically reasonable and necessary at this time. A re-evaluation 
after the approved sessions is appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 20 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 20 additional PT visits. 
 
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.