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

 
We decided that the Plan does not have to pre-approve the Minuteman Fusion Plate. 
 
You asked the Plan to pre-approve the Minuteman Fusion Plate. You say that the enrollee has a past medical 
history of chronic low back pain and right lower extremity pain. You say the enrollee had a lumbar epidural 
steroid injection, trigger point injection, and sacroiliac joint injection all with no improvement in the pain. The 
Plan denied your request. The Plan says the requested Minuteman Fusion Plate 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 pre-approve the Minuteman Fusion Plate. Our 
reviewer says that the requested Minuteman Fusion Plate is not considered medically reasonable and necessary. 
Our physician reviewer found that the Minuteman device is experimental. More research is needed. 
 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 Minuteman Fusion Plate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman Fusion Plate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 12, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have been caught in an endless cycle of 
denials, and this claim should be reconsidered. The Plan denied your request. The Plan says you billed these 
services with a non-covered modifier. 
 
The Plan must follow Medicare rules. The rules say that modifiers from -HA through -HZ are non-covered by 
Medicare, and all services billed with these modifiers will be denied.  In this case, you billed the services in 
dispute with modifier -HE.  This modifier falls within the range of modifiers that are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on May 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on August 9, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says per Local Coverage 
Article A58761, this type of testing must be billed with a single unit of service of 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 lab panel provided on August 9, 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 
September 5, 2023, and billed with codes 87500, 87641, 87798, G0452, 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 September 5, 2023, 
and billed with codes 87500, 87641, 87798, G0452, 87481, 87651, and 87653.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 17, 2023, billed with 
procedure codes 99309-SA and G8427-HE. 
 
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 billed modifiers are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that several Healthcare Common Procedural Coding 
System (HCPCS) modifiers are used to signify a specific line item is either not covered or not payable by 
Medicare.  
We looked at the file and Medicare rules. The claim was billed with an inappropriate modifier. Based on this 
information, we decided that Medicare rules for coverage of the practitioner services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on March 17, 
2023, billed with procedure codes 99309-SA and G8427-HE.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for laparoscopy, surgical; cholecystectomy (47562) provided on July 12, 
2023. 
 
You asked the Plan to pay for laparoscopy, surgical; cholecystectomy. You say that you were not aware of the 
prior authorization requirements. The Plan denied your request. The Plan says that the service was not 
authorized. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laparoscopic cholecystectomy services by a contract provider. The contracted 
surgeon who performed the services did so with a non-contracted assistant surgeon. You would not have 
reasonably known that the surgery would require an assistant surgeon, nor would you have reasonably known 
who this assistant surgeon would be. The file does not show that the Plan provided notice that the assistant 
surgeon services provided during the laparoscopic cholecystectomy would not be covered. Under Medicare 
rules, this means the services provided by an out-of-network (OON) assistant surgeon are considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for laparoscopy, surgical; cholecystectomy (47562) 
provided on July 12, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 3, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have been caught in an endless cycle of 
denials, and this claim should be reconsidered. The Plan denied your request. The Plan says you billed these 
services with a non-covered modifier. 
 
The Plan must follow Medicare rules. The rules say that modifiers from -HA through -HZ are non-covered by 
Medicare, and all services billed with these modifiers will be denied.  In this case, you billed the services in 
dispute with modifier -HE.  This modifier falls within the range of modifiers that are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83520 billed for August 18, 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 code 83520 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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. 
 
We find that CPT code 83520 is not supported in the medical record. Specifically, the records show that fecal 
calprotectin by ELISA testing was performed and there is a more appropriate code for these services. 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 83520 billed for August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 14, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have been caught in an endless cycle of 
denials, and this claim should be reconsidered. The Plan denied your request. The Plan says you billed these 
services with a non-covered modifier. 
 
The Plan must follow Medicare rules. The rules say that modifiers from -HA through -HZ are non-covered by 
Medicare, and all services billed with these modifiers will be denied.  In this case, you billed the services in 
dispute with modifier -HE.  This modifier falls within the range of modifiers that are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the periodontal scaling and root planing (D4341) for all 4 
quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says that the denial of authorization for these services is 
correct, because x-rays do not show that there is a hard substance built up on the root of the teeth. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the periodontal scaling and root planing is medically reasonable and necessary. Our physician reviewer 
found that the documentation indicates the presence of pathologic periodontal pockets of 5-6mm and greater in 
all quadrants along with evidence of calculus buildup. The periodontal scaling and root planing is medically 
reasonable and necessary to treat the enrollee's periodontal disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve the periodontal scaling and root planing (D4341) for all 4 quadrants.  
 
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 lab services provided on June 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that you do not accept walk-ins and do not have access 
to the patient's insurance information prior to the date of service. 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 June 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that if discharged home, you will be at risk of getting 
bed sores and infection. The Plan denied your request. The Plan says the records do not show that you require 
skilled nursing services or daily skilled therapy that can only be provided on an inpatient basis. 
 
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 pre-approve 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 clinical documentation shows that you have had clinical and functional status change 
thus you would be expected to require continued assessment by skilled therapy and skilled nursing. Clinical 
documentation shows that your past level of function was bed bound. Clinical documentation shows that you 
are currently requiring total assist with mobility and self-care tasks thus there are no specified inpatient daily 
skilled therapy goals. Clinical documentation does not specify any daily skilled nursing needs thus daily skilled 
services are not supported. As a practical matter, clinical documentation does not support the medical necessity 
of daily skilled services on an inpatient basis in a skilled nursing facility.  
 
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 pre-approve skilled nursing facility (SNF) care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed on July 26, 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 two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that N23.0 has an Excludes1 note in relation to R10.31. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for 
the emergency room (ER) services billed on July 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a pneumatic compression device (E0675) provided on 
January 25, 2023, through February 13, 2023. 
 
You asked the Plan to pay for  a pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
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 on January 25, 2023, through February 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service from July 
16, 2023, to August 12, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service from July 16, 2023, to August 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 December 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical and oral therapy services provided from June 22, 
2023, to June 29, 2023. 
 
You asked the Plan to pay for physical and oral therapy services. You say that you needed these services. The 
Plan denied your request. The Plan says these services exceeded the therapy cap. 
 The Plan must follow Medicare rules. Medicare rules say that there is a $3,000 cap amount as a threshold of 
incurred expenses above which claims must include a modifier as a confirmation that services are medically 
necessary as justified by appropriate documentation in the medical record. All covered and medically necessary 
services qualify for exceptions to caps. All requests for exception are in the form of a KX modifier added to 
claim lines.  
 
We looked at the file and Medicare rules. The record shows that you reached the $3,000 cap amount for 2023, 
and the services at issue were not billed with a KX modifier to request and exception. Based on this 
information, we decided that Medicare rules for coverage of physical and oral therapy services have not been 
met. Therefore, we decided that the Plan does not have to pay for physical and oral therapy services provided 
from June 22, 2023, to June 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positive emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging for a limited area (78814). 
 
You asked the Plan to pre-approve a PET with CT. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the type of picture study requested is not supported for the 
enrollee's condition. 
 
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 PET with CT. Our reviewer says that 
the requested PET scan with CT is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates that this service is being requested for a bone scan. The reviewer found that the provided documentation does not include prior or current imaging reports to 
support that this service is necessary. Therefore, the reviewer found that the requested PET scan with CT 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 a PET with CT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positive emission tomography (PET) scan with concurrently acquired computed 
tomography (CT) for attenuation correction and anatomical localization imaging for a limited area (78814).