Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 87798, 87481, 87653 and 87641 billed for date of 
service April 17, 2023. 
 
You asked the Plan to pay for procedure codes 87798, 87481, 87653 and 87641. You say that these services 
were necessary and were reported appropriately. The Plan denied your request. The Plan says that the payment 
for these codes is included in the payment for code 87801. Although a modifier was used to request separate 
payment, the records provided do not support that this modifier was used appropriately. 
 
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 
87798, 87481, 87653 and 87641 are column II codes to column I code 87801; however, 87798, 87481, 87653 
and 87641 were each billed with a modifier.  
 
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 procedure codes 87798, 87481, 87653 and 87641. Our 
reviewer says that the medical record supports these codes as reported. Our reviewer found the documentation 
does support the use of codes 87798, 87481, 87653 and 87641 to be billed with modifier 59 or XU as they were 
separate from code 87801. The provider tested for these organisms with the urinary tract infection and the 
codes used are to the highest specificity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87798, 87481, 87653 and 87641 have been met. Therefore, we 
decided that the Plan has to pay for procedure codes 87798, 87481, 87653 and 87641 billed for date of service 
April 17, 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 practitioner services provided on June 15, 2023, billed with 
procedure code 00532-QX-P3.  
 
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 claim was billed with an inappropriate 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If the side is not identified in the medical record, assign the code for the unspecified side. 
 
We looked at the file and Medicare rules. It is not appropriate to report and unspecified diagnosis when a more 
appropriate code exists. 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 June 15, 2023, billed with procedure code 00532-QX-P3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9603 rendered on August 10, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the prior findings are upheld for code P9603, as the claim does not meet coding standards. 
 
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 P9603 is "Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled." 
 
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 services at issue in this case were not supported by the medical records. Our reviewer found that the documentation does not 
include sufficient documentation to verify services performed per Medicare guidelines, which include: The 
allowance is intended to cover the transportation and personnel expenses for trained personnel to travel to the 
location of an individual to collect the sample. The medical record documents a "Accessioner," however 
verification cannot be made for a trained technician that collected the specimen. 
 
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 procedure code P9603 rendered on August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 31, 2022, billed with 
procedure code 01992. 
 
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 diagnosis is inconsistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that it is not appropriate to bill Medicare for services 
that are not covered (as described by the entire LCD) as if they are covered. 
 
We looked at the file and Medicare rules. The claim was not billed with a diagnosis from the list of diagnoses 
that support medical necessity. 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 May 31, 2022, billed with procedure code 01992.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the aminolevulinic acid provided on June 
7, 2023. 
 
You asked the Plan to waive the coinsurance for the aminolevulinic acid. You say that you are requesting the 
cost share be waived. 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 $59.40, which is 20% of the coinsurance of the allowed amount for the 
aminolevulinic acid. 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 the aminolevulinic acid provided on June 7, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient behavioral health admission. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary and appropriate. The Plan denied your request. The Plan says that this stay is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that the requested inpatient psychiatric admission is appropriate in this case. Our physician 
reviewer found that the enrollee presented on November 13, 2023, with Schizoaffective Disorder, Bipolar 
Type, Posttraumatic Stress Disorder, Generalized Anxiety Disorder, Cannabis Abuse, Uncomplicated, Cocaine 
Abuse, Uncomplicated and Insomnia Unspecified. Based upon review the records provided it was expected this 
enrollee would improve in a reasonable period of time beyond the dates in question as he was showing 
dangerousness to self or others, auditory but no visual hallucinations. He was not showing any symptoms of 
withdrawal, any difficulties with medical condition or mental health condition. The patient was cooperative and 
compliant with medication. It did appear medically necessary and reasonable to have psychiatric/detoxification 
care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question 
as he did have any suicidal and homicidal thoughts. This enrollee did require inpatient mental 
health/detoxification treatment as noted above as he was a danger to himself and/or others. It did appear that 
active treatment was taking place beyond the date in question. It did appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the patients condition or for the purpose 
of diagnosis. Based upon review the records provided, this patient does meet the criteria for treatment in an 
acute inpatient/detoxification treatment beginning November 13, 2023, and could not have been treated in a 
lesser restrictive 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 inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve an inpatient behavioral health admission.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), a limited oral 
evaluation (D0140), the intraoral radiographic images (D0220 and D0230), a crown (D2740) for tooth #4, a 
partial upper denture (D5820), and to pay for a cleaning (D1110), a partial upper denture (D5213), and a bone 
replacement graft (D7953) provided on May 2, 2023, May 5, 2023, May 25, 2023, and June 6, 2023. 
 You asked the Plan to pay more for the dental services. You say that you were never informed that you would 
need oral surgery and the partial plate did not fit in your mouth correctly. The Plan denied your request. The 
Plan says your annual dental maximum benefit for the year has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $27 for dental services on April 13, 2023. On May 2, 2023, the Plan paid $331.50 for 
dental services. On May 16, 2023, the Plan paid $623 for dental services. On May 25, 2023, the Plan paid $18 
for dental services. For the year of 2023 the Plan paid $1,000 ($27 paid + $331.50 paid + $623 paid + $18 paid) 
for dental services; therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the 
date of service of May 25, 2023. Therefore, we decided that the Plan does not have to pay more for a periodic 
oral evaluation (D0120), a limited oral evaluation (D0140), the intraoral radiographic images (D0220 and 
D0230), a crown (D2740) for tooth #4, a partial upper denture (D5820), and to pay for a cleaning (D1110), a 
partial upper denture (D5213), and a bone replacement graft (D7953) provided on May 2, 2023, May 5, 2023, 
May 25, 2023, and June 6, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Synvisc One. 
 You asked the Plan to pre-approve Synvisc One. You say that Synvisc One is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of Synvisc One have not 
been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc One. Our reviewer says that 
treatment with Synvisc One is not medically reasonable and necessary in this case. Our physician reviewer 
found that the Plan requires a trial of all of their preferred products (Durolane, Euflexxa, GelSyn 3 and Supartz 
FX). Although the enrollee has tried Euflexxa, medical records show that the enrollee has not failed all of the 
preferred products nor does the enrollee have a contraindication to all of them. The documentation does not 
outline contraindications or reasons these medications were not considered or that the Plan's required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Synvisc One.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99305-25 rendered on June 12, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99305 25 24 (1 Unit) remains 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 99305 is "Initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using total time on the date of the encounter for code 
selection, 35 minutes must be met or exceeded." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report describes 
wound assessment and wound care performed. The records do not include documentation of a significant, 
separately identifiable evaluation and management (E&M) service above and beyond what was associated with 
the wound care provided. Therefore, separate payment for evaluation and management service 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99305-25 rendered on June 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 12, 2020, 
to December 1, 2020, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says the medical 
records did not have sufficient documentation to clinically validate the diagnosis of E43 (unspecified severe 
protein-calorie malnutrition). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with E43 defined as unspecified severe protein-calorie 
malnutrition. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 
rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the 
DRG originally billed. Our physician reviewer found documentation does not provide sufficient evidence to 
support diagnosis code E43 (unspecified severe protein-calorie malnutrition).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 12, 2020, to December 1, 2020, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 17, 2023, by an out-
of-network (OON) provider.  
 
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 services were provided by an out of network 
provider. 
 
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 practitioner services provided on March 17, 2023, 
by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on August 
9, 2023. 
 
You asked the Plan to pay for the ED services. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on August 9, 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 you would like to file an appeal for the denial of a 
SNF admission. The Plan denied your request. The Plan says you do not meet the requirements for approval. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have identifiable skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist; however, you do not 
require skilled therapy services on a daily basis. You do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a skilled nursing facility (SNF) setting. You do not meet severity of illness or intensity 
of service criteria for an inpatient basis in a 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 skilled nursing facility (SNF) care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services provided February 11, 2023, by a 
facility not enrolled in Medicare. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says this facility is not enrolled in Medicare. 
 
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 services have not been met. This facility is an independent freestanding emergency department (IFED) and is not enrolled in Medicare. No documentation has been 
submitted to show that this provider is affiliated with a hospital. The services at issue were provided during the 
COVID-19 Public Health Emergency (PHE). No documentation has been submitted to show that this provider 
is enrolled as a temporary hospital during the PHE. As such, this provider is not eligible for Medicare payment. 
Therefore, we decided that the Plan does not have to pay for the emergency services provided February 11, 
2023, by a facility not enrolled in Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1852). 
 
You asked the Plan to pre-approve a knee orthosis. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested item 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 a knee orthosis. Our reviewer says that 
the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no ligamentous instability or knee deformity. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1852).