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

 
We decided that the Plan does not have to pay for procedure codes 20611 and 99213 billed for May 19, 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 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 20611 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording 
and reporting. 
 
We find that CPT code 20611 is not supported in the medical record. Specifically, there is no documentation of 
permanently recorded images. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. Procedure code 99213 is within the global surgery period of code 
20611 provided on May 19, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 20611 and 99213 billed for May 
19, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are appealing the denial with supporting 
records. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 that you do not require the level of observation and treatment provided in terms of 
physician oversight and skilled nursing care. You do not require skilled nursing services. You may continue to 
benefit from therapy or assistance. However, this does not require the intensity of skilled therapy services 
provided in the skilled nursing facility setting. 
 
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 SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for treatment with bevacizumab (J9035). 
provided on April 06, 2023. 
 
You asked the Plan to waive the coinsurance for treatment with bevacizumab (J9035).. You say that that the 
Plan pays almost nothing again and again. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for treatment with bevacizumab (J9035).. This item/service falls 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for treatment with bevacizumab (J9035). provided on April 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2377, E2313, E2311) and 
the backpack holder (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics and the backpack holder. You say that the 
requested items are medically necessary. The Plan denied your request. The Plan says the upgraded electronics 
exceed the enrollee's need and are not medically reasonable or necessary. The Plan also says that the backpack 
holder does not serve a medical need and cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has sufficient strength and function in the upper extremities to 
manage standard power drive controls. 
 
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 upgraded electronics have not been met. The backpack holder does not serve 
a medical purpose. Therefore, we decided that the Plan does not have to pre-approve the upgraded electronics 
(E2377, E2313, E2311) and the backpack holder (K0108).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 28, 2022, to 
October 27, 2022. 
 You asked the Plan to pay for the home health services. You say that the required NOA was submitted. 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 August 29, 2022. The NOA was not received by the Plan until January 27, 
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 September 28, 2022, to October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the tests should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on October 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 1, 
2023, to March 2, 2023. 
 You asked the Plan to pay for SNF care. You say that the records provided support the services. The Plan 
denied your request. The Plan says the enrollee has no daily skilled nurse or therapist needs. 
 
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 pay for 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 pay for skilled nursing facility (SNF) care provided from February 1, 2023, to March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (97810, 98941) provided on March 17, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the out-of-network services were not pre-approved or emergent. There 
were network providers available. 
 
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 services at issue in this appeal. 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 chiropractic services (97810, 98941) provided on March 17, 2023, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 36556 and 99292 billed for date of service March 10, 
2023.  
 
You asked the Plan to pay for codes 36556 and 99292. You say that this was billed correctly. The Plan denied 
your request. The Plan says these codes 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 36556 is insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. The definition of 99292 is critical care, evaluation and 
management of the critically ill or critically injured patient; each additional 30 minutes (List separately in 
addition to code for primary procedure). 
 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 codes 36556 and 99292. Our reviewer says that the billed 
codes are not supported. Our reviewer found the procedure report does not include sufficient documentation to 
confirm that non-tunneled centrally inserted central venous catheter insertion was performed to support 36556. 
The records also document only 42 minutes of critical care time, meaning it is not appropriate to report 99292 
for additional time beyond the 30 to 74 minutes billed with 99291. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 36556 and 99292 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 36556 and 99292 billed for date of service March 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's acute needs have been met 
and stabilized in the acute care setting and they are stable to transfer to the LTACH for the continuation of care.  
The Plan denied your request. The Plan says the records do not show that it is medically necessary to be in an 
LTACH in place of an acute care hospital. 
 
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 that the enrollee appears to still be somewhat unstable and requires additional 
acute care hospital services that can safely be provided at the current facility until more stable and appropriate 
for transfer. 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 is not medically necessary as the enrollee is not yet 
stable for transfer and as it would not be clinically advantageous.  
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11042 billed for date of service April 24, 
2023.  
 
You asked the Plan to pay for procedure code 11042. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 11042 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 11042 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 11042 billed for date of service April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36561, 76937 and 77001 billed for January 
4, 2023. 
 
You asked the Plan to pay for procedure codes 36561, 76937 and 77001. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the provided records do not support the 
services 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 CPT codes 36561, 76937 and 77001 are not supported in the medical record. Specifically, medical 
records for the date of service at issue have not been provided. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 36561, 76937 and 77001 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 36561, 76937 and 77001 billed for January 4, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are unable to support yourself. The Plan denied 
your request. The Plan says the coverage criteria has not been met. 
 
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 that you are functioning at a home care level. Daily skilled services are not medically 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you were not timely provided with the 
correct diagnosis. The Plan denied your request. The Plan says this claim was not filed timely 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until April 10, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on March 11, 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. The Plan denied your 
request. The Plan says the enrollee can be treated at a lower level of care. 
 
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 while the enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement, she does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, at 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusion (96365, 96366) and refilling and 
maintenance of a portable pump (96521) provided on April 13, 2023. 
 
You asked the Plan to pay for intravenous infusion and refilling and maintenance of a portable pump. You say 
that you disagree with the denial and have submitted medical records for review. The Plan denied your request. 
The Plan says codes 96365, 96366 and 96521 remain 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 intravenous infusion and refilling and maintenance of a 
portable pump. Our reviewer says that the service does not meet criteria. Our reviewer found that for CPT 
96365, documentation submitted was reviewed, and does not meet criteria. Procedure report describes 
intravenous insulin treatment provided for outpatient. In this case there is a more specific code that should be 
reported for service documented. For CPT 96366, documentation submitted was reviewed, and does not meet 
criteria. Procedure report describes intravenous insulin treatment provided for outpatient. In this case there is a 
more specific code that should be reported for service documented. For CPT 96521, documentation submitted 
was reviewed, and does not meet criteria. Medical record includes documentation of refilling and maintenance 
of portable pump; however, documentation does not support procedure was performed, and therefore cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intravenous infusion and refilling and maintenance of a portable pump have not 
been met. Therefore, we decided that the Plan does not have to pay for intravenous infusion (96365, 96366) 
and refilling and maintenance of a portable pump (96521) provided on April 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of a second chest x-ray provided on April 
25, 2023, billed with code 71045-26-77. 
 
You asked the Plan to pay for the services as billed. You say that this should be payable as a second x-ray was 
interpreted the same day. The Plan denied your request. The Plan says modifier 77 should not be used when the 
procedure is repeated by the same physician. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier 77 is used for repeat services by a 
different physician. 
 
We looked at the file and Medicare rules. The file shows that this service was repeated by the same physician. 
Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of a second chest x-ray 
provided on April 25, 2023, billed with code 71045-26-77.