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

 
We decided that the Plan does not have to pay for procedure codes 93040, 93790, 36000, 99070, 99072, and 
A4930 billed for May 10, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93040 is rhythm ECG, 1-3 leads; with interpretation and 
report. The definition of 93790 is ambulatory blood pressure monitoring, utilizing report-generating software, 
automated, worn continuously for 24 hours or longer; review with interpretation and report. 
 
We find that CPT codes 93040 and 93790 are not supported in the medical record. Specifically, there is no 
interpretation and report to support code 93040. There is no documentation of ambulatory blood pressure 
monitoring with report-generating software for 24 hours or longer to support code 93790. 
 
The rules say that providers must report services correctly. Providers must report services with the appropriate 
procedure code. 
 
Billed procedure codes 36000, 99070, and 99072 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 36000, 99070, and 99072 are not separately payable. Billed procedure code 
A4930 has a status indicator of X on the Physician Fee Schedule. This means that procedure code A4930 is 
excluded from Medicare.  
 
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 93040, 93790, 36000, 99070, 
99072, and A4930 billed for May 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 
for November 19, 2022. 
 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 11, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 for 
November 19, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on November 1, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that switching therapists is not an option. The Plan 
denied your request. The Plan says this provider is not part of the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on  
November 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the reinsertion of a spinal fixation device (22849) and 
the exploration of the spinal fusion (22830). 
 
You asked the Plan to pre-approve the spinal surgery. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says this procedure 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 the spinal surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the detailed documentation is not evident regarding imaging or radiographic 
evidence clearly supporting hardware failure of the right sacroiliac (SI) joint. There is no clear failure of 
conservative treatment directed to the SI joint since the previous fusion procedure on March 17, 2023. There is an apparent discrepancy between the radiologist's and the attending physician's imaging report findings. There 
are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 spinal surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the reinsertion of a spinal fixation device (22849) and the exploration of the spinal 
fusion (22830).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (88381, 81455, G0463) provided on 
November 16, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you would like the medical records reviewed 
and the claim to be reprocessed and paid. The Plan denied your request. The Plan says the request does not 
meet Medicare rules as the testing performed was not FDA approved. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the requested test is not FDA approved and 
therefore, is not a covered benefit with the Plan. Therefore, we decided that the Plan does not have to pay for 
laboratory services (88381, 81455, G0463) provided on November 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20936 billed for date of service February 14, 
2023. 
 
You asked the Plan to pay for procedure code 20936. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 20936 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 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service February 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection procedure provided on January 27, 2023.  
 
You asked the Plan to pay for the injection procedure. You say that this should be paid due to medical necessity 
of the services. The Plan denied your request. The Plan says the reported POS code is not valid.  
 
The Plan must follow Medicare rules. Medicare rules say that for services rendered to a registered inpatient, 
POS code 21 should be used.  
 
 
 
 
 
 
 We looked at the file and Medicare rules. The claim is billed with the outpatient hospital POS code 22. The file 
shows that the enrollee was admitted as an inpatient on the date of service. Based on this information, we 
decided that Medicare rules for coverage of the injection procedure have not been met. Therefore, we decided 
that the Plan does not have to pay for the injection procedure provided on January 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the WATS oral Brush CDx biopsy test coded as 88112, 
88305, 88312 and 88361 provided May 26, 2022. 
 
You asked the Plan to pay for  the laboratory service. You say that please reconsider your claim following the 
Medicare guidelines. The Plan denied your request. The Plan says the clinical value and effectiveness of WATS Oral Brush CDx biopsy test in the setting of oral mucositis have 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for  the WATS oral Brush CDx biopsy test coded as 88112, 88305, 88312 and 88361 provided May 26, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for  provided on November 29, 2022, to December 14, 2022. 
 
You asked the Plan to pay for  Zirabev. You say that the services were medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says that the services are determined to be experimental and 
are not covered.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Zirabev. Our reviewer says that the 
medication was medically necessary. Our physician reviewer found the National Comprehensive Cancer 
Network (NCCN) guidelines support the use of Zirabev for the enrollee's condition. The documentation 
provided supports that Zirabev is safe and effective and otherwise reasonable and necessary for this 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 Zirabev have been met. Therefore, we decided that the Plan has to pay for  
provided on November 29, 2022, to December 14, 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: 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 the enrollee currently meets full IRF criteria. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
IRF.  
 
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: 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 an expedited appeal for the denial 
of an IRF admission. You say treatment is not consistent with published clinical evidence. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 99100 billed for date of service February 15, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim should be paid. 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 February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99491 billed for date of service December 
19, 2022.  
 
You asked the Plan to pay for procedure code 99491. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99491 is bundled into payment for code G0181. 
 
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 99491 
is a column II code to column I code G0181 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 99491 billed for date of service December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 01630 and 64415 billed for July 14, 2022. 
 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 01630 and 64415 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 01630 is anesthesia for open or surgical arthroscopic 
procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not 
otherwise specified. 
 
We find that CPT code 01630 is not supported in the medical record. Specifically, the documentation contains 
an illegible anesthesia report that does not support that anesthesia for open or surgical arthroscopic procedures 
on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint was performed. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 64415 
is a column II code to column I code 01630. 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 codes 01630 and 64415 billed for July 
14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service June 13, 
2022.  
You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 3 for CPT code 99153. This means there 
is only a technical component for the CPT code. This code is not payable as billed. Based on this information, 
we decided that Medicare rules for coverage of procedure code 99153 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99153 billed for date of service June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided on February 13, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for OON mental health services. You say that you have been seeing this provider for 
many years. The Plan denied your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that authorization rules 
apply for out-of-network outpatient mental health care services.  
 
We looked at the file and Medicare rules. The service at issue was not authorized. Based on this information, 
we decided that Medicare rules for coverage of OON mental health services have not been met. Therefore, we 
decided that the Plan does not have to pay for mental health services provided on February 13, 2023, by an out-
of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services billed with code 97530 for January 19, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the billed diagnosis codes are not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the billed diagnosis codes exclude each other. 
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 the therapy services billed with code 97530 for 
January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 76942 billed for date of service 
November 28, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 76942. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 76942 is bundled into payment for code 
36556. Procedure code 99100 is 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 CPT code. In this case, we have confirmed that code 76942 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. 
 
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 the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 99100 and 76942 billed for date of service November 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mammogram provided on January 23, 2023. 
 
You asked the Plan to pay for the mammogram. You say that the doctor saw something on the mammogram 
and wanted you to get a second mammogram done. The Plan denied your request. The Plan says the service is 
a covered benefit, but the enrollee has exceeded limits set in the subscriber agreement for number of 
mammograms done in a calendar year. 
 
The Plan contract covers one screening mammogram every 12 months for women age 40 and older. 
 
We looked at the file and the Plans rules. The file shows that you had a mammogram done four days earlier on 
January 19, 2023. Based on this information, we decided that the Plans rules for coverage of the mammogram  
have not been met. Therefore, we decided that the Plan does not have to pay for a mammogram provided on 
January 23, 2023.