Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial with supporting medical 
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 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 that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. The enrollee can receive further 
services at a lower level of care. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99214) provided April 6, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
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. The service at issue is within the global surgery period of code 64493 
provided on April 6, 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 physician services (99214) provided 
April 6, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 27 physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the requested therapy services are 
medically necessary. The Plan denied your request. The Plan says there has been adequate time since the start 
of care to instruct and transition the enrollee and caregivers in a home program to maintain strength. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the goals of therapy are to increase strength and endurance. The 
enrollee has remained at 4/5 strength throughout their therapy sessions. Strength and endurance training is 
repetitive exercise. The enrollee does not require the continued unique skills of a therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 27 physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
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 services are medically necessary. Our physician reviewer found based upon review 
of the records provided this enrollee does meet criteria for acute inpatient mental health treatment as although 
this enrollee was not shown to be a danger to herself or others. There were no auditory or visual hallucinations 
noted. She is noted to be uncooperative and non-compliant with treatment while showing aggressive behaviors. 
 
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 inpatient psychiatric hospital services.  
 
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 procedure code 93355 billed for date of service April 4, 
2023.  
 
You asked the Plan to pay for procedure code 93355. You say that this code is not included with any other 
procedure. The Plan denied your request. The Plan says payment for code 93355 is bundled into payment for 
code 00560. 
 
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 93355 is a column II code to column I code 00560 with a modifier 
indicator of 0. The column II code is 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 code 93355 
billed for date of service April 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual application of stress performed by physician or 
other qualified health care professional for joint radiography, including contralateral joint if indicated provided 
on September 9, 2022. 
 
You asked the Plan to pay for the x-ray stress view. You say that the medical records submitted supports CPT 
code 77071-26 and should be paid. The Plan denied your request. The Plan says that the modifier used is a 
Professional/Technical component and cannot be used with code 77071. 
 
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 77071 is the manual application of stress performed by 
physician or other qualified health care professional for joint radiography, including contralateral joint if 
indicated. 
 
We find that CPT code 77071-26 is not supported in the medical record. Specifically, CPT code 77071 has a 
Pro/Tech flag of 2 in the Physician Fee Schedule. This means that it is a stand-alone code that describes the 
physician work portion of selected diagnostic tests for which there is an associated code that describes the 
technical component of the diagnostic test only and another associated code that describes the global test. 
Modifiers 26 and TC cannot be used with these codes. This code was inappropriately reported with modifier 
26. Based on this information, we decided that Medicare rules for coverage of x-ray stress view (77071) have 
not been met. Therefore, we decided that the Plan does not have to pay for the manual application of stress 
performed by physician or other qualified health care professional for joint radiography, including contralateral 
joint if indicated (x-ray stress view) (77071) provided on September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on February 24, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for outpatient hospital services. You say that the services performed were medically 
necessary. The Plan denied your request. The Plan says an authorization was not obtained prior to services 
rendered. 
 
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 outpatient hospital services provided on February 
24, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service February 14, 
2023. 
 You asked the Plan to pay for procedure code 88374. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says payment for code 88374 is bundled into 
payment for code 88321. 
 
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 88374 
is a column II code to column I code 88321. 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 88374 billed for date of service February 14, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 8, 2023, billed with 
codes 81238, 81291, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that the treatment sought was medically 
necessary. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single code as 
required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 8, 2023, billed with codes 81238, 81291, and 81479.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair you purchased on March 25, 2023. 
 
You asked the Plan to pay for the lift chair. You say that you suffered a fall where you fractured your left 
clavicle and two vertebrae. You needed assistance getting out of chair, so your doctor suggested a lift chair. 
You said that it is your understanding that lift chairs are covered by Medicare. The Plan denied your request. 
The Plan says you purchased this item from a non-Medicare certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider from whom you purchased the lift chair at 
issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
lift chair you purchased on March 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service April 12, 2023. You asked the Plan to pay for the billed services. You say that the test was ordered based on the physician's 
training. The Plan denied your request. The Plan says the test is not a covered service. 
 
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 panel testing was not billed with a single code as required. The test is not approved by the 
Food and Drug Administration. The documentation does not show that the test underwent a technical 
assessment to determine whether Medicare reasonable and necessary requirements are met. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for the panel testing billed for date of service April 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 14, 2023, by an 
out-of-network provider. You asked the Plan to pay for the laboratory services. You say that you were not aware that you only had a 
$3,000 out-of-network benefit limit. The Plan denied your request. The Plan says your POS coverage limit has 
already been exhausted. 
 
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. There is a POS coverage limit of $3,000 per calendar year. Once 
this limit is reached, you are responsible for 100% of the cost of the out-of-network services. 
 
The record shows your POS coverage limit has been exhausted. You have been asked to pay $135 for the 
laboratory services provided on March 14, 2023. 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 pay for the laboratory 
services provided on March 14, 2023, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the high sensitivity C-reactive protein (hsCRP) testing 
(86141) provided October 22, 2021.  
 
You asked the Plan to pay for the laboratory service. You say that you tried to contact the enrollee for correct 
information but was not able to obtain this information timely. The Plan denied your request. The Plan says the 
claim was submitted after the timely filing limitation. 
 
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 service was not filed until March 21, 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 high sensitivity C-reactive protein (hsCRP) testing (86141) 
provided October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9578 provided on December 21, 2022. 
 
You asked the Plan to pay for procedure code A9578. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 A9578 is not supported in the medical record. Specifically, the National Drug Code on 
the claim form does not match the provided drug documented in the records. Based on this information, we 
decided that Medicare rules for coverage of procedure code A9578 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code A9578 provided on December 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service April 12, 2023. You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the test is not a 
covered service. 
 
We looked at the file and the rules. We find that the urinary tract infection panel was not billed with a single 
code as required. The records do not show that this testing was necessary above the standard of care. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the panel testing billed for date of service April 12, 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. The Plan denied your 
request. The Plan says your care needs are considered custodial. 
 
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 daily skilled nursing and/or skilled therapy services. You are 
medically stable and can receive further rehabilitation services at a lower level of care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided 
from March 1, 2022, through March 3, 2022. 
 
You asked the Plan to pay for a water circulating heat pad with pump (E0217). You say that there is evidence 
based medical literature that substantiates the efficacy of the treatment rendered. You say that this is medically 
necessary, and the charges should be paid in full. The Plan denied your request. The Plan says a water 
circulating heating pad with a pump is non-covered because it is not considered reasonable and necessary. 
 
  The Plan must follow Medicare rules say that a moist electric heating pad (E0215) or water circulating heat pad 
with pump (E0217) is not reasonable and necessary compared to a standard electric heating pad (E0210); 
therefore, if code E0215 or E0217 is provided it will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump (E0217) have not been met. Specifically, a water 
circulating heat pad with pump (E0217) is not considered medically necessary. Therefore, we decided that the 
Plan does not have to pay for a water circulating heat pad with pump (E0217) provided from March 1, 2022, 
through March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87426 and 99152 provided on July 19, 
2022. 
 
You asked the Plan to pay for procedure codes 87426 and 99152. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the 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. 
 
In this case, the CPT Code Manual definition of code 87426 is Infectious agent antigen detection by 
immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], 
fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; 
severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]). The definition of 
code 99152 is Moderate sedation services provided by the same physician or other qualified health care 
professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence 
of an independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intra-service time, patient age 5 years or older. 
 
We find that CPT codes 87426 and 99152 are not supported in the medical record. Specifically, the records do 
not include a laboratory report and order and do not indicate the intra-service time for moderate sedation 
services. Based on this information, we decided that Medicare rules for coverage of procedure codes 87426 and 
99152 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87426 
and 99152 provided on July 19, 2022.