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

 
We decided that the Plan does not have to pay for procedure code 99417 billed for date of service March 29, 
2023. 
 
You asked the Plan to pay for procedure code 99417. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99417 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99417 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99417 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99417 billed for date of service March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 31, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in an 
assisted living facility. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on March 17, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on March 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiology testing in a facility provided on January 10, 2023. 
 
You asked the Plan to pay for cardiology testing in a facility. You say that you depend on the facility staff to 
verify eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for cardiology testing in a 
facility provided on January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, hereditary 
hypercoagulability) gene analysis, Leiden variant (81241). 
 
You asked the Plan to pre-approve the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden 
variant.. You say that this testing is medically necessary. The Plan denied your request. The Plan says this 
testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for F2 and F5 genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant parties. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the F2 gene analysis, 20210G>A variant and F5 gene analysis, Leiden variant. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, 
hereditary hypercoagulability) gene analysis, 20210G>A variant (81240) and F5 (coagulation factor V) (eg, 
hereditary hypercoagulability) gene analysis, Leiden variant (81241).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97140, 97161, and 97535 billed for 
February 27, 2023, to March 2, 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 codes 97140, 97161, and 97535 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 97140 is manual therapy techniques (eg, mobilization/ 
manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. The definition 
of code 97161 is physical therapy evaluation: low complexity, requiring these components: A history with no 
personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using 
standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or 
uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient 
assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent 
face-to-face with the patient and/or family. The definition of code 97535 is self-care/home management 
training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, 
and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 
minutes. 
 
We find that CPT codes 97140, 97161, and 97535 are not supported in the medical record. Specifically, the file 
shows that the services were performed in the home setting and there are more appropriate codes for these 
services. 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 codes 97140, 97161, and 
97535 billed for February 27, 2023, to March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99359 and 99358 billed for date of service 
February 15, 2023. 
 
You asked the Plan to pay for procedure codes 99359 and 99358. You say that the patient didn't choose to see 
this provider.  Rather, this provider had no knowledge of which patients they would see at the facility. The Plan 
denied your request. The Plan says the billed codes are invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure codes 99359 and 99358 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99359 and 99358 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99359 and 99358 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99359 and 99358 billed for 
date of service February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the GeneSight Psychotropic test (81479) provided 
September 9, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you request reconsideration of the denial. The 
Plan denied your request. The Plan says GeneSight Psychotropic test 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 the file and Medicare rules. GeneSight Psychotropic test is a combinatorial pharmacogenomic 
test. Insufficient evidence exists to support the use of this test. GeneSight Psychotropic has not been shown to 
be useful and is not considered medically necessary and appropriate and is a noncovered test per DEX 
Diagnostics Exchange Registry. Based on this information, we decided that Medicare rules for coverage of the 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for  the GeneSight 
Psychotropic test (81479) provided September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
15, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not progressing and needs intensive 
inpatient rehabilitation. The Plan denied your request. The Plan says admission to an IRF is not medically 
necessary.  
 
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 complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
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 IRF. 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo device (0266T, C1825). 
 
You asked the Plan to pre-approve a Barostim Neo device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees clinical management. 
 
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 Barostim Neo device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo device (0266T, C1825).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64495 billed for date of service March 2, 
2023. 
 
You asked the Plan to pay for procedure code 64495. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this service was not medically 
necessary and was not pre-approved. 
 
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 pay for procedure code 64495. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Medicare rules state that one to two levels, either unilateral or bilateral, are allowed 
per session per spine region. The provider did not provide evidence of such a unique circumstance for a third 
level with sufficient documentation of medical necessity. The review has determined that the enrollee does not 
meet the criteria for the requested procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64495 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 64495 billed for date of service March 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (80307, G0481) provided on February 
9, 2022. 
 
You asked the Plan to pay for drug testing. You say that the services at issue were a medical necessity for the 
enrollee. 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 the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of drug testing have been met. 
Specifically, no physician order or requisition has been provided for the services at issue. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for drug testing services (80307, G0481) provided on February 9, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right thread carpal tunnel release (64999). 
 
You asked the Plan to pre-approve right thread carpal tunnel release. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 right thread carpal tunnel release. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. The documentation does not support 
any therapy, medications, physical therapy, or a follow-up examination after the provided steroid injection on the July 13, 2023 exam. The overall surgery would not be supported with the lack of conservative treatment 
measures. Therefore, the requested right thread carpal tunnel release is not medically reasonable or 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 right thread carpal tunnel release have not been met. Therefore, we decided that 
the Plan does not have to pre-approve right thread carpal tunnel release (64999).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological testing evaluation services (96130 x6), 
neuropsychological testing evaluation services (96132 x6), and psychological or neuropsychological test 
administration and scoring by technician (96138 x6). 
 You asked the Plan to pre-approve psychological testing evaluation services, neuropsychological testing 
evaluation services, and psychological or neuropsychological test administration and scoring by technician. 
You say that the requested testing is not self-administered or scored, but are performed, documented, and 
scored by a technician. You also say that these services are medically necessary. The Plan denied your request. 
The Plan says the measures requested are all brief screening tests that the enrollee can complete independently 
in significantly less time than is being requested. The Plan also says that this appeal request for 15 hours of 
testing is not reasonable or necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that if the total time for the tests exceeds eight hours, a 
report may be requested asking for the medical necessity of the extended testing. 
 
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 psychological testing evaluation 
services, neuropsychological testing evaluation services, and psychological or neuropsychological test 
administration and scoring by technician. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the documentation 
available for review does not support medical necessity for the requested 15 hours of neuropsychological and 
psychological testing that has been requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychological testing evaluation services, neuropsychological testing evaluation 
services, and psychological or neuropsychological test administration and scoring by technician have not been 
met. Therefore, we decided that the Plan does not have to pre-approve psychological testing evaluation services 
(96130 x6), neuropsychological testing evaluation services (96132 x6), and psychological or 
neuropsychological test administration and scoring by technician (96138 x6).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93978 & 93975 billed for date of service 
January 17, 2023. 
 You asked the Plan to pay for procedure codes 93978 & 93975. You say that this service was medically 
necessary. The Plan denied your request. The Plan says payment for code 93978 is bundled into payment for 
code 93975. 
 
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 93978 
is a column II code to column I code 93975. This claim has not been billed with an appropriate modifier to 
bypass the edit. Code 93976 better describes the limited duplex scan performed. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 93978 & 93975 billed for date of service January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 11, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on October 11, 2022.