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

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
March 13, 2023. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that the services were medically 
necessary due to the symptoms on the exam. You say that the documentation should be reviewed, and the claim 
reprocessed accordingly. The Plan denied your request. The Plan says procedure code 20930 and 20936 are 
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 codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure code 20930 and 20936 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 17, 2023. 
 
You asked the Plan to pay for the domiciliary, rest home visit. You say that the member was residing at a 
assisted living facility and the physician was not responsible to obtain authorization. You say that the assisted 
living facility is responsible to obtain prior authorization for all their patients, which should also cover the 
medical treatments provided by this physician. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service April 10, 
2023. 
 You asked the Plan to pay for procedure code 99284. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 99284 is bundled into payment for 
code 99285. 
 
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 99284 
is a column II code to column I code 99285. 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 99284 billed for date of service April 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on February 21, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that NOAs are submitted using TOB 032A. 
 
We looked at the file and Medicare rules. The file shows that the Notice of Admission (NOA) was not 
submitted using type of bill 032A. 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 the home health 
services rendered on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood bank physician services billed with code 86077 for 
January 20, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed with the correct place of service code. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for the blood bank physician services billed with code 86077 for January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services (99443) provided on November 11, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is 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 CPT code. 
 
We find that CPT code 99443 is not supported in the medical record. Specifically, this service is included in 
code 99215 which was also billed. Based on this information, we decided that Medicare rules for coverage of 
the telehealth services have not been met. Therefore, we decided that the Plan does not have to pay for 
telehealth services (99443) provided on November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 12, 2023. 
 
You asked the Plan to pay for the medical services. You say that this claim is not a duplicate and was denied 
incorrectly. The Plan denied your request. The Plan says you billed this claim with an incorrect Place of 
Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 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 12, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the transcatheter placement of intravascular stents in the cervical 
carotid artery and intracranial artery (61635 and 37216). 
 
You asked the Plan to pre-approve the services requested with codes 61635 and 37216. You say that it is felt 
that the requested services should be approved.  The Plan denied your request. The Plan says that vertebral 
artery stenting is not covered by Medicare.  
 
Review of the services which were requested and denied, we find that there was no request for vertebral artery 
stenting made, and that the only two services remaining at issue after the partial approval by the Plan were 
stenting of the two vessels noted on the first page of this letter. As such, we find that the Plans argument was 
not applicable to the issues at review in this case.  
 
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 services requested with codes 61635 
and 37216. Our reviewer says that the requested services in this case are considered medically reasonable and 
necessary. Our physician reviewer found the enrollee is a 72-year-old patient with a diagnosis of a left vertebral 
artery dissection with recurrent symptoms of syncope and vision loss. Carotid artery and vertebral artery 
angiography have been requested and approved by the health plan. The plan denied requests to cover 
angioplasty and stenting of cervical carotid and intracranial arteries.  
 
Based on the medical records provided there is support in the documentation that the angioplasty and stenting 
of cervical carotid and intracranial arteries is eligible for coverage under Medicare guidelines. However, the 
angioplasty and stenting would only meet criteria for payment if the findings of the angiography medically 
support it.  
 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 requested with codes 61635 and 37216 have been met. Therefore, 
we decided that the Plan has to pre-approve the transcatheter placement of intravascular stents in the cervical 
carotid artery and intracranial artery (61635 and 37216).  
 
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 pre-approve a referral to an out-of-network oncologist. 
 
You asked the Plan to pre-approve these services. You say that the local providers will not treat you because of 
your age. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan confirmed that the network 
providers are available to see you. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network 
oncologist.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87486 and 87581 
for date of service June 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test must not be 
unbundled and billed as individual components regardless of the fact that the panel reports multiple individual 
pathogens and/or targets. 
 
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. Therefore, we decided that the Plan does not have to pay 
for the laboratory services billed with codes 87486 and 87581 for date of service June 14, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from January 8, 2022, to February 6, 
2022. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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's denial indicates that the home health services at issue 
were incorrectly reported as an institutional admission. However, the provided medical records do not support a 
community admission. The Plan has not provided documentation of its assertion of a community admission, so 
we must find in your favor. Therefore, we decided that the Plan has to pay for home health services provided 
from January 8, 2022, to February 6, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of a modality to 1 or more areas; electrical 
stimulation (manual), each 15 minutes (97032) and the drugs and administration (J3490, J3411, J3415, J3420, 
J1955, 96372) provided on January 18, 2023. 
 
You asked the Plan to pay for the services. You say that  reprocess this claim and pay this claim. The Plan 
denied your request. The Plan says your request is not medically necessary because your records show 
Medicare guidelines say that electrical nerve stimulation treatments furnished by a physician in his/her office, 
by a physical therapist or outpatient clinic are excluded from coverage by section 1862(a)(1) of the Act. The 
Plan states Medicare guidelines additionally indicate that electrostimulation for the treatment of neuropathies 
caused by systemic disease is not reasonable and necessary, and medical management using systemic 
medications should instead be employed. The Plan states the subcutaneous injection of the pharmaceutical 
blend substances are not covered. The Plan states Medicare says that use of the drug or biological must be safe 
and effective and otherwise reasonable and necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Review of the file and publicly 
available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA 
who is not licensed to provide physical therapy in the State of Ohio. The multiple drug codes reported on this 
claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be 
billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, 
payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also 
cannot be paid. Furthermore, the rules say that electrical nerve stimulation treatments furnished by a physician 
in his/her office, by a physical therapist or outpatient clinic are excluded from coverage by Section 1862(a)(1) 
of the Act. 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 the application of a modality to 1 or 
more areas; electrical stimulation (manual), each 15 minutes (97032) and the drugs and administration (J3490, 
J3411, J3415, J3420, J1955, 96372) provided on January 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64420 and 64421 billed for date of service 
October 13, 2022.  You asked the Plan to pay for procedure codes 64420 and 64421. 

You say that breast reconstruction should be 
a covered procedure. The Plan denied your request. The Plan says payment for codes 64420 and 64421 are 
bundled into payment for code 19380. 
 
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 64420 and 64421 are column II codes to column I code 19380 with 
a modifier indicator of 0. The column II codes are 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 codes 64420 and 64421 billed for date of service October 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 9, 2022, to 
January 6, 2023. 
 You asked the Plan to pay for the home health services. You say that you believed you submitted the NOA in a 
timely manner. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
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 November 9, 2022. The NOA was not received by the Plan until February 
6, 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 home health services provided 
from December 9, 2022, to January 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 14, 2023. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that the home health services are not supported in the medical record. Specifically, the claim was not 
billed with a valid type of bill. Based on this information, we decided that Medicare rules for coverage of the 
home health services have not been met. Therefore, we decided that the Plan does not have to pay for home 
health services provided on March 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
January 9, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 is used only for 
peripheral artery disease. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pneumatic compression device have not been met. The record does not show this device was 
ordered for the treatment of peripheral artery disease. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (E0675) provided on January 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87798, and 87641 billed for date of 
service September 26, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87798, and 87641. You say that you disagree with the 
denial. The Plan denied your request. The Plan says payment for codes 87150, 87798, and 87641 is bundled 
into payment for code 87500. 
 
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 
87150, 87798, and 87641 are column II codes to column I code 87500. This claim has not been billed with an 
appropriate modifier to bypass the edit. The -XU modifier is not supported as a separate and distinct procedural 
service. 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 codes 87150, 87798, and 87641 billed for date of service 
September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the one-way travel allowance (P9604) provided August 5, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that please review the medical record attached. 
The Plan denied your request. The Plan says the billed services were 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 P9604 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip charge. 
 
We find that CPT code P9604 is not supported in the medical record. Specifically, the documentation 
submitted do not include a travel log for one way in connection with medically necessary laboratory specimen 
collection or drawn from homebound or nursing homebound patient. Based on this information, we decided 
that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the 
Plan does not have to pay for the one-way travel allowance (P9604) provided August 5, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on February 1, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider is out-of-network, there is no pre-authorization process, no 
referral from the primary physician, no medical emergency and there are 16 contract providers in the member's 
living area with the specialty of Psychiatry. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on February 1, 2023.