Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97110, 97140, 97530) provided on 
January 11, 2023. 
 
You asked the Plan to pay for physical therapy services. You say that these services were medically necessary 
and are supported in the medical record. The Plan denied your request. The Plan says this claim was submitted 
with incompatible diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a diagnosis code has an Excludes1 note, it is inappropriate to report the noted condition together with the condition with the note.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, this claim was submitted with diagnosis 
codes R26.9 and R27.0. However, codes within the R26 code set have an Excludes1 note with code R27.0. It is 
generally inappropriate to report these codes together. Therefore, we decided that the Plan does not have to pay 
for physical therapy services (97110, 97140, 97530) provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service February 13, 
2023 to February 27, 2023. 
 
You asked the Plan to pay for procedure code 97010. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service February 13, 2023 to February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9342 billed for date of service January 1, 
2023, to January 19, 2023. 
 
You asked the Plan to pay for procedure code S9342. You say that your organization has a contracted rate for 
this service. 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 S9342 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9342 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9342 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9342 billed for date of service January 1, 2023, to January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99442 billed for January 27, 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 code 99442 is 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 99442 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 11-20 minutes of medical discussion. 
 
We find that CPT code 99442 is not supported in the medical record. Specifically, the records show that code 99215 for an office visit was billed for this enrollee on January 20, 2023 by the same provider; therefore, the 
telephone evaluation is not applicable. 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 
code 99442 billed for January 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80048, 83550, 83540, 82728, 85027) 
provided on May 16, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported in the medical record. The Plan denied your request. The Plan says the primary diagnosis code 
reported for this claim is not appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that In diseases classified elsewhere codes are 
never permitted to be used as first listed or principal diagnosis codes. They must be used in conjunction with an 
underlying condition code, and they must be listed following the underlying condition. 
 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 primary diagnosis reported on this claim is 
B96.89 (other specified bacterial agents as the cause of diseases classified elsewhere). It is not appropriate to 
report this in diseases classified elsewhere code as a primary diagnosis. Therefore, we decided that the Plan 
does not have to pay for laboratory services (80048, 83550, 83540, 82728, 85027) provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided on March 16, 2022. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the Plan has 
insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. In 
addition, documentation should support the level of service reported. 
 
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 the inpatient care have been met. 
Therefore, we decided that the Plan does not have to pay for inpatient care provided on March 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac perfusion imaging. 
 
You asked the Plan to pre-approve cardiac perfusion imaging. You say that cardiac perfusion imaging is 
medically necessary. The Plan denied your request. The Plan says cardiac perfusion imaging is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac perfusion imaging is covered when the 
criteria listed in the Medicare rules section of this decision are met.  
 
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 cardiac perfusion imaging. Our 
reviewer says that the requested cardiac perfusion imaging is not considered medically necessary in this case. 
Our physician reviewer found that the enrollee has had no cardiac signs or symptoms. The enrollee was 
described as having a history of back strain from carrying grandchildren, for which she was treated with 
analgesic. There is no evidence provided that would support the need for radionuclide stress testing at this time. 
In summary, there is insufficient documentation to support the medical necessity for the requested cardiac 
stress testing 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 cardiac perfusion imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve cardiac perfusion imaging.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on February 7, 
2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were billed a $10 copay for an 
annual physical visit. 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 $25 
copayment for Physician/Practitioner services.   

You have been asked to pay a $25 copayment for the office visit provided on February 7, 2023. This service 
falls within the Physician/Practitioner services benefit category. The record shows that additional issues were 
addressed outside of the annual physical exam. 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 copayment for the office 
visit provided on February 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on February 2, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for wound care supplies. You say that this was medically necessary and shouldn't 
need authorization. The Plan denied your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may offer a Point of Service (POS) option 
and may either require or waive prior authorization rules for obtaining POS services. The Plan contract states 
that prior authorization is required for out-of-network durable medical equipment (DME) and related supplies 
and for surgical supplies, such as dressings.  
We looked at the file and Medicare rules. The items at issue were not authorized. Based on this information, we 
decided that Medicare rules for coverage of wound care supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for wound care supplies provided on February 2, 2023, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 83718, 81403, 
81402 and 81406 on June 6, 2022. 
 
You asked the Plan to pay for laboratory codes 83718, 81403, 81402 and 81406. You say that these services 
were medically necessary. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of laboratory codes 
83718, 81403, 81402 and 81406 have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services billed with codes 83718, 81403, 81402 and 81406 on June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84436 and 84480 billed for date of service 
March 9, 2022.  You asked the Plan to pay for procedure codes 84436 and 84480. 

You say that these services were necessary and were reported appropriately. The Plan denied your request. The Plan says payment for codes 84436 and 84480 is bundled into payment for codes 84439 and 84481. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
84436 and 84480 are column II codes to column I codes 84439 and 84481 with modifier indicators of 0. The 
column II codes are 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 codes 84436 and 84480 billed 
for date of service March 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2023, to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2023, to February 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of 
a ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and was 
recently hospitalized with an exacerbation. Arterial blood gas (ABG) was consistent with acute on chronic 
hypercarbic respiratory failure. There are no pulmonary function tests to confirm obstruction and assess 
severity. There is no ABG done while stable to confirm chronic carbon dioxide (CO2) retention.  If that is 
present, the enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured 
pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a home ventilator when used 
at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22514 and 99152 rendered on December 2, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the 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 the denied codes is: 
 
CPT 22514: 
 
Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral 
cannulation, inclusive of all imaging guidance; lumbar 
 
CPT 99152: 
 
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 intraservice time, patient age 5 years or older 
 
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 both codes are not supported in 
the records. There is no documentation of bone cavity creation, or appropriate sedation measures. 
 
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 codes 22514 and 99152 rendered on December 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says transferring from the acute care hospital to a long-term 
acute care hospital would not give the enrollee any additional benefit. Services needed may be provided safely 
in a lower level of care.  
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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 long term acute care hospital (LTACH) 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 every doctor says you need acute rehabilitation.  The 
Plan denied your request. The Plan says your medical needs could be met in a skilled nursing unit. 
 
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 you have no complex nursing or rehabilitation needs. You do not require treatment 
by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program.  There is not a reasonable expectation that you 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 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 subsequent hospital inpatient or observation care provided on 
April 7, 2023. 
 
You asked the Plan to pay for subsequent hospital inpatient or observation care. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the Plan must pay for care from 
out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
This provider is not a network provider with the Plan. It has also determined that these services are not urgent 
or emergent, nor were they approved in advance, therefore, we have upheld our original determination. 
 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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent hospital inpatient or observation care provided on 
April 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81455 billed for date of service February 18, 
2023. 
 
You asked the Plan to pay for procedure code 81455. You say that you have billed the services at issue 
correctly. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
  We find that CPT code 81455 is not supported in the case record. Specifically, medical records corresponding 
to date of service February 18, 2023, have not been provided. Based on this information, we decided that 
Medicare rules for coverage of procedure code 81455 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 81455 billed for date of service February 18, 2023.