Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal test (81479) provided February 6, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you provide the Guardant Reveal molecular 
diagnostic test at the request of the ordering physician. The Plan denied your request. The Plan says this testing 
is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Per DEX Diagnostics Exchange Registry, Guardant Reveal is 
not covered by Medicare. Per 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 
Guardant Reveal test (81479) provided February 6, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve additional chiropractic services for treatment of your neck pain. 
 
You asked the Plan to pre-approve additional chiropractic services. You say that you are appealing the denial. 
The Plan denied your request. The Plan says that that you have already received the Medicare allowed 12 
annual chiropractic appointments. 
 
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 has not obtained records from the provider to aid in decision making. 
There is a lack of evidence showing that you have already received the maximum 12 annual visits. Without 
these records, we cannot determine if how many chiropractic services you have received. The Plan is 
considered to be in control of medical records from network providers. Therefore, the Plan has not shown that 
its decision to deny authorization for this service is correct or justified. Therefore, we decided that the Plan has 
to pre-approve additional chiropractic services for treatment of your neck pain.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable X-ray services provided on March 7, 2023. 
 
You asked the Plan to pay for portable X-ray services. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, 
they are often provided to serve an entity for which another POS code exists. If the mobile unit is serving an 
entity for which another POS code already exists, providers should use the POS code for that entity. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of portable X-ray services have not been met. Specifically, the services at issue were reported with 
POS code 11, indicating an outpatient office setting. The case record does not support POS code 11. Therefore, 
we decided that the Plan does not have to pay for portable X-ray services provided on March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry office visit provided on September 21, 2022, by 
an OON provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service was not authorized. 
 
 
 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 the podiatry office visit provided on September 
21, 2022, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service September 27, 
2022, to October 19, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. 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 September 27, 2022. The NOA was not received by the Plan. 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 services for date of service 
September 27, 2022, to October 19, 2022.
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 this is medically necessary to treat your condition 
because you would be seen daily by physicians, which would reduce your risk of returning back to hospital. 
Medically necessary care can be provided in a different level of care. The Plan denied your request. The Plan 
says the services you need can be provided safely in other settings.  
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program.  
 
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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 97140 billed for date of service November 16, 2021. 
 
You asked the Plan to pay for procedure code 97140. You say that this service was coded appropriately for 
separate payment. The Plan denied your request. The Plan says that this code cannot be paid when it is billed 
with code 29581. 
 
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 has not forwarded the provided the medical records or 
original claim for review. Although we do not have a copy of the original claim, the clinical review summary 
indicates that the code at issue was reported with modifier 59. Although code 97140 is generally included in 
code 29681, it is possible to report both services with an appropriate modifier, such as modifier 59. There is no 
evidence that the use of this modifier was reviewed by the Plan. No medical records were forwarded to us to 
verify that this modifier was reported inappropriately, and there is no evidence from the Plan that there were no 
records provided but attempts were made to obtain them. The Plan has not substantiated their denial with a 
complete review in this case. Therefore, we decided that the Plan has to pay for procedure code 97140 billed 
for date of service November 16, 2021.  
 
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 Cxbladder Monitor test (0013M) provided February 14, 
2023. 
 
You asked the Plan to pay for the laboratory services. You say that  you are appealing the denial of coverage 
for the Cxbladder Monitor test. The Plan denied your request. The Plan says the Cxbladder panel remains 
unproven at this time. 
 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. 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 Cxbladder Monitor test (0013M) provided February 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for January 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 procedure code 99285 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function.  
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 these services. Our reviewer says that procedure code 99285 
is not supported. Our reviewer found the enrollee presented to the emergency department (ED) with his wife 
reporting he had confusion since the previous night and increasing lower extremity edema. The enrollee was 
without complaints. He was diagnosed with leg edema. The records do not support that the examination was 
comprehensive or that there was medical decision making of high complexity. Code 99285 is not supported by 
the submitted records. 
 
We looked at this coder's review, the file, and Medicare rules. 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 99285 billed for January 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Monitor test (0013M) provided February 17, 
2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial of coverage for 
the Cxbladder Monitor test. The Plan denied your request. The Plan says the CX Bladder panel remains 
unproven at this time. 
 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. 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 Cxbladder Monitor test (0013M) provided February 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a total electric hospital bed (E0265) provided April 16, 2023. 
 
You asked the Plan to pay for the hospital bed. You say that please review the medical records and process the 
claim for payment. The Plan denied your request. The Plan says total electric hospital beds are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for a total electric hospital bed 
(E0265) provided April 16, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 97140 billed for date of service December 2, 2021. 
 
You asked the Plan to pay for procedure code 97140. You say that this service was coded appropriately for 
separate payment. The Plan denied your request. The Plan says that this code cannot be reported with code 
29581. 
 
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 has not forwarded the provided the medical records or 
original claim for review. Although we do not have a copy of the original claim, the clinical review summary 
indicates that the code at issue was reported with modifier 59. Although code 97140 is generally included in 
code 29681, it is possible to report both services with an appropriate modifier, such as modifier 59. There is no 
evidence that the use of this modifier was reviewed by the Plan. No medical records were forwarded to us to 
verify that this modifier was reported inappropriately, and there is no evidence from the Plan that there were no 
records provided but attempts were made to obtain them. The Plan has not substantiated their denial with a 
complete review in this case. Therefore, we decided that the Plan has to pay for procedure code 97140 billed 
for date of service December 2, 2021.  
 
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: ER
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on March 24, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this provider is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare is creating additional flexibilities to 
allow licensed independent freestanding emergency departments (EDs) to participate in Medicare and 
Medicaid to help address the urgent need to increase hospital capacity to provide care to patients.  
 
We looked at the file and Medicare rules. The services in this case were provided by a freestanding emergency 
facility prior to the end of the COVID-19 emergency period. As such, these services are payable in this case. 
Based on this information, we decided that Medicare rules for coverage of the services have been met. 
Therefore, we decided that the Plan has to pay for the services provided on March 24, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided in the hospital from 
April 19, 2023, to April 20, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
in the hospital from April 19, 2023, to April 20, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee orthosis (L1851). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that no instability of the right knee joint has been reported. 
 
The Plan must follow Medicare rules. Medicare rules say that a knee orthosis is covered for knee injury where 
there is knee instability demonstrated on examination. 
 
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. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the plan has erred in its denial of L1851.  Dispensing first with the issue of the reasonable useful 
lifetime brought up in the Plans first denial, the request at hand is not for a replacement of the left knee brace, 
it is for a new brace on the right.  Replacement timelines therefore are irrelevant to this case, but we should 
note in any event that Policy Article A52465 establishes a 3-year useful life of L1851, not 5 years. 
 
As to the remaining issue at hand, the surgeon's notes document the enrollee to be ambulatory, with functional 
instability due to severe pain. The enrollee has a history of medical meniscus tear on the left and instability 
since 2020. This is confirmed on visual and radiological exam, hence why the surgeon has ordered not only a 
brace but a walker as well to prevent him from falling. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a knee orthosis (L1851).  
 
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 the home health services provided on June 3, 2021. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. The first digit for 
admission source is not valid as it was reported as institutional. Per Federal Register Final Rule Vol. 84, No. 
217 dated November 8, 2019 to qualify this 30-day payment period for institutional admission source, the 
documentation would require that the patient had a qualifying inpatient acute-care stay in the 14 day allowable 
timeframe of May 20, 2021  June 2, 2021. Per the CMS (Center for Medicare and Medicaid Services) Manual 
System, Pub 100-04 Medicare Claims Processing only inpatient stays with bill types of 111, 117 (Inpatient acute hospitalization admission) and 211, 212, or 214 (Skilled Nursing Facility Inpatient admission) qualify for 
the institutional admission source. Per the enrollee's claims data information the patient has not had any 
inpatient stays with a bill type of 111, 117, 211, 212, or 214 in the 14 day allowable window of May 20, 2021  
June 2, 2021. There is no other documentation in the records submitted to support the the enrollee having an 
inpatient hospital admission in the 14 day allowable window to be considered for inpatient admission source. 
Therefore, the claim was also denied for inpatient admission source is not supported. The records submitted did 
not include visits notes for all of the visits billed on the claim. The Health Insurance Prospective Payment 
System (HIPPS) code billed is not supported. The home health agency did not submit sufficient documentation 
to support that the billed code was correct.  Therefore, we decided that the Plan does not have to pay for the 
home health services provided on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99152) provided on March 22, 2023. 
 
You asked the Plan to pay for the 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. 
 
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 use of code 99152 is 
not supported by the records provided. Our reviewer found that code 99152 is included with the colonoscopy 
codes processed. 
 
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 the services (99152) provided on March 22, 2023.