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

 
We decided that the Plan does not have to pre-approve vertebroplasty. 
 You asked the Plan to pre-approve vertebroplasty. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 vertebroplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation of bracing. 
More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertebroplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vertebroplasty.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from July 1, 
2021, to July 28, 2021. 
 
You asked the Plan to pay for the services. You say that you submitted supporting documentation for 
reconsideration of DRG adjustment. The Plan denied your request. The Plan says the provider has reported 
skilled services with the incorrect PDPM Health Insurance Prospective Payment System (HIPPS) score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 while chronic obstructive 
pulmonary disease (COPD) and malnutrition are noted on a diagnosis list, there is no evidence that the 
diagnoses existed or actively affected the course of care. 
 
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 skilled nursing facility (SNF) services rendered from July 1, 2021, to July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on February 14, 2022, billed with 
codes 37252 and 37253. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 definitions of codes 37252 and 37253 is Intravascular ultrasound 
(noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological 
supervision and interpretation; initial noncoronary vessel, and Intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel.  
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 testing services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the documentation is missing key 
components of the code descriptions. The codes in question 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 testing services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for testing services provided on February 14, 2022, billed with codes 37252 and 
37253.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 9, 2022, to 
February 23, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted all required data. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 10, 2022. The NOA was not received by the Plan until May 4, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 9, 2022, to February 23, 2022.
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 the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
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 enrollee does not need this item. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure support 
(AVAPS) capability and failure of such a device has not been documented.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 billed for date of service December 7, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the testing was 
not coded correctly. 
 
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 G0481 is definitive drug testing of 8-14 drug classes. We 
find that CPT code G0481 is not supported in the medical record. Specifically, the records show that more than 
14 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
G0481 billed for date of service December 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for placement of soft tissue localization device(s) (eg, clip, 
metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion rendered 
on November 3, 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 this is part of the primary procedure and not eligible for separate payment. 
 
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 10035 is "Placement of soft tissue localization device(s) 
(eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first 
lesion."  
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 the medical records provided 
document CPT 19083 was performed. CPT 10035 has a bundled relationship to CPT code 19083. National 
Correct Coding Initiative (NCCI) rules allows the use of a modifier to unbundle this relationship providing the 
medical records support the use of the modifier. In this case, the medical records provided does not include 
sufficient documentation to validate that 10035 was performed as a separate/distinct procedure, independent 
from other services performed by the same physician during the same operative session, therefore it is 
inappropriate to append modifier 59 to this code and no additional reimbursement is allowed. 
 
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 placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive 
seeds), percutaneous, including imaging guidance; first lesion rendered on November 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service June 10, 2022. 
 
You asked the Plan to pay for the billed services. You say that the pathology report was submitted. The Plan 
denied your request. The Plan says the service is not covered. 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. The provided know error testing is statutorily excluded from 
coverage. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of service 
June 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on December 21, 2022. 
 
You asked the Plan to pay for the testing. 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 the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on December 21, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that continued SNF care is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not have daily skilled nursing or therapy needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee no longer qualifies for SNF coverage. The enrollee does not have 
documented skilled nursing or therapy needs. The enrollee is ambulating and tending to ADLs with minimal 
supervision. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 30, 2022. 
 
You asked the Plan to pay for the services. 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 services at issue were reimbursed 
by the Plan on July 21, 2022. 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 the services have not been met. Therefore, we decided 
that the Plan does not have to pay for the services provided on June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 12, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on January 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on December 30, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that this device was 
provided for use during the patient's surgery. The Plan denied your request. The Plan says equipment used in a 
facility for a procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and appliance provided on December 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83036 billed for date of service November 
14, 2022. 
 
You asked the Plan to pay for procedure code 83036. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted with 
a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 83036. Any codes which are not listed are considered not medically necessary for 
code 83036. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 83036 have not been met. Specifically, this claim was submitted with diagnosis codes which are not among those codes listed as medically necessary and appropriate for this service. 
Therefore, we decided that the Plan does not have to pay for procedure code 83036 billed for date of service 
November 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81518) provided on December 2, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for genetic testing. You say that the requested service is covered by Medicare and 
therefore should be covered by the Health Plan. The Plan denied your request. The Plan says services are 
covered only if the enrollee's provider or other network provider gets approval in advance, a prior 
authorization. Outpatient laboratory tests are noted on the Medical Benefits Chart on page 63 as requiring prior 
authorization. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for genetic testing (81518) provided on December 2, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service February 14, 
2023.  
 You asked the Plan to pay for procedure code 86077. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87636 for date of service January 18, 2023. 
 
You asked the Plan to pay for procedure code 87636. You say that you disagree with the Plan's denial. 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 procedure code 87636 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87636 for date 
of service January 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these tests were medically 
necessary and reasonable. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial 
of a SNF admission. The Plan denied your request. The Plan says you do not meet the Medicare rules for 
coverage of SNF care.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.