Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95955, 95885, and 95907 for date of service 
November 18, 2021. 
 
You asked the Plan to pay for procedure codes 95955, 95885, and 95907. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the documentation does not support the codes 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 95955, 95885, and 95907 are not supported in the medical record. Specifically, the 
technical report did not include documentation of electroencephalogram (EEG)  during nonintracranial surgery 
(eg, carotid surgery); therefore, code 95955 cannot be verified. 
 
The technical report did not include needle electromyography, each extremity, with related paraspinal areas, 
when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in 
addition to code for primary procedure); therefore, code 95885 cannot be verified. 
 
The technical report did not include documentation of nerve conduction studies; 1-2 studies; therefore, code 
95907 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 95955, 95885, and 
95907 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 95955, 
95885, and 95907 for date of service November 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided from October 14, 2022, to 
October 19, 2022. 
 
You asked the Plan to pay for the skilled nursing services. You say that you billed this claim with a 0120 
revenue code because there was a Patient Driven Payment Model (PDPM) score. The Plan denied your request. 
The Plan says you did not bill the appropriate revenue code. 
 
The Plan must follow Medicare rules. Medicare rules say that under the PDPM model, SNF PPS services must 
be billed with revenue code 0022. 
 
In this case, you did not bill revenue code 0022 on the claim.  You only billed revenue codes 0120, 0420, and 
0430.  The Plan has indicated that it will accept a corrected claim from you. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing services provided from October 14, 2022, to October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device (E2311). 
 
You asked the Plan to pre-approve an electronic connection device. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says there is no medical 
need to control the power option through the joystick.  
 
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 an electronic connection device. 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 does have use of the upper extremities and can 
operate/control the power options using the switches that are included in the power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection device (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 13, 2022, billed 
with codes 81227, 81231, 81232, 81291, 81306, 81335, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 panel 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 
December 13, 2022, billed with codes 81227, 81231, 81232, 81291, 81306, 81335, and 81238.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 87652 provided on February 7, 2023. 
 
You asked the Plan to pay for procedure code 87652. You say that the medical records support the billing of 
code 87652. The Plan denied your request. The Plan says that the medical records do not support the billing of 
code 87652. 
 
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 87652 is Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, 
quantification. 
 
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 code 87652. Our reviewer says that the medical 
records support the billing of code 87652. Our reviewer found there is documentation stating that group A 
streptococcus was tested for and was negative.  
 
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 code 87652 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87652 provided on February 7, 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: 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 in their current condition, the enrollee 
cannot be adequately cared for at a lower level of care as exhibited by a recent failed discharge resulting in 
readmission. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
admission an LTACH.  
 
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 all medically necessary care is being provided in the current acute care setting.  
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 the nursing facility care provided on February 24, 2023. 
 
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. 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 nursing facility care 
provided on February 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 8, 2021, to 
January 28, 2021. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that for - 
 
We reviewed the file and the Medicare rules. We find that the claim is not payable as billed. The date of service 
does not match the HIPPS code, G code, and Q codes. Based on this information, we find that the Medicare 
rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from January 8, 2021, to January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code(s) 88341 -XU, 88342-XU and 88360-XU billed for date of service March 19, 2021.

You asked the Plan to pay for procedure code(s) 88341 -XU, 88342-XU and 88360-XU. You say that you disagree with the denial. The Plan denied your request. The Plan says this code is included in the skilled nursing facility payment and is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Technical components must be billed by the SNF for its Part A inpatients and are not separately payable.

The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee Schedule, CPT code 88341 -XU, 88342-XU and 88360-XU have a Professional/Technical indicator of 1. This means that CPT code 88341 -XU, 88342-XU and 88360-XU have both a professional and technical component. In this case, CPT code 88341 -XU, 88342-XU and 88360-XU have not been billed with an appropriate modifier to indicate the professional component. Based on this information, we decided that Medicare rules for coverage of procedure code 88341 -XU, 88342-XU and 88360-XU have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 88341 -XU, 88342-XU and 88360-XU billed for date of service March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of an intraorifice barrier (D3911) for tooth #30 
provided on February 21, 2023. 
 
You asked the Plan to pay for the dental service. You say that the provider never told you prior to getting the 
work done that the services would not be covered. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the placement of an intraorifice barrier is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
placement of an intraorifice barrier (D3911) for tooth #30 provided on February 21, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 81479 and 81301 provided on September 23, 2022. 
 
You asked the Plan to pay for procedure codes 81479 and 81301. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for procedure codes 81479 and 81301 by a contract provider. The file does not show 
that the plan provided notice that procedure codes 81479 and 81301 would not be covered. Under Medicare 
rules, this means procedure codes 81479 and 81301 are considered approved by the plan. Therefore, we 
decided that the Plan has to pay for procedure codes 81479 and 81301 provided on September 23, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76604 billed for date of service February 2, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the procedure was rendered in the appropriate 
place of service. The Plan denied your request. The Plan says the claim was not billed with an appropriate place 
of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We find that CPT code 76604 was billed with an outpatient place of service code (22). The enrollees claim 
information shows that they were an inpatient at the time the services were provided. 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 procedure code 76604 billed for date of service February 2, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CardioMEMS device (93264) provided on March 8, 
2023. 
 
You asked the Plan to pay for the CardioMEMS device. You say that the device implantation (code 33289) was 
determined to be favorable and paid on December 30, 2022. You also say that since the device implantation 
was proven effective and has been paid, the monitoring of the device (code 93264) should also be paid. The 
Plan denied your request. The Plan says the clinical value and effectiveness of the CardioMEMs device has not 
been demonstrated in the peer-reviewed literature.  
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 the CardioMEMS 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 a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. Our reviewer also found that 
as a result, at this time the CardioMEMS system would not be considered medically appropriate 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 the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pay for the CardioMEMS device (93264) provided on March 8, 2023.
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 you are requesting reconsideration for the denial of 
an IRF admission based on medical necessity. The Plan denied your request. The Plan says the request for an 
IRF admission 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95165 rendered on January 2, 2023. 
 
You asked the Plan to pay for the services. You say that the medical records should be reviewed. The Plan 
denied your request. The Plan says Current Procedural Terminology (CPT) code 95165 (24 units) 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 95165 is "Professional services for the supervision of 
preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number 
of doses)." 
 
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 CPT code 95165 for the date of 
service in question is not supported. The records submitted are from a different date of service. There are no 
records in the case file for the date of service in question. CPT code 95165 and the units reported 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 95165 rendered on January 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Part B drugs, diagnostic radiology and eye 
exam on January 10, 2023, to January 23, 2023.  
 
You asked the Plan to waive the cost share for Part B drugs, diagnostic radiology and eye exam. You say that 
you want to appeal the amount being charged. 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 a 20% 
coinsurance for all other drugs covered under Medicare Part B. Covered drugs include drugs that usually aren't 
self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, 
or ambulatory surgical center services. You must pay a $300 for each Medicare-covered diagnostic radiology 
service other than CT scans. You must pay a $75 copayment for each Medicare-covered diagnostic procedure 
and test. Covered services include but are not limited to other outpatient diagnostic tests. You must pay a $30 
copayment for services for the diagnosis and treatment of diseases and injuries of the eye. Covered services 
include outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, 
including treatment for age-related macular degeneration. The provider billed in the amount of $2,088 and the 
allowed amount is $1,310.80 for the service. $1,310.80 x 20% = $262.16. The provider also billed in the 
amount of $110 and the allowed amount is $70.75 for the service. $70.75 x 20% = $14.15. The provider also 
billed in the amount of $612 and the allowed amount is $384.20 for the service. $384.20 x 20% = $76.84. For 
the services, $300 + $75 + $262.16 + $14.15 + $76.84 + $30 = $758.15. Therefore, resulsts in the total cost 
sharing amount of $758.15.   
 
You have been asked to pay a 20% coinsurance for Part B drugs, a $300 copayment and $75 copayment for 
diagnostic radiology and a $30 copayment for eye exam. This item/service falls within the Medicare Part B 
prescription drugs, outpatient diagnostic tests and therapeutic services and supplies and vision care 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 cost share for Part B drugs, diagnostic radiology and eye exam 
on January 10, 2023, to January 23, 2023.