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

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service December 5, 
2022. 
 You asked the Plan to pay for procedure code 11721. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 11721 is bundled into payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 code 11721 billed for date of service December 5, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary, and the enrollee's needs can be met at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76937-26 billed for date of service January 3, 
2023. 
 You asked the Plan to pay for procedure code 76937-26. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 76937-26 is bundled into 
payment for code 93985. 
 
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 
76937-26 is a column II code to column I code 93985. 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 code 76937-26 billed for date of service 
January 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 2, 2023, to 
January 19, 2023 
 You asked the Plan to pay for the home health services. You say that the required NOA was submitted. 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 December 3, 2022. The NOA was not received by the Plan until March 21, 
2023. 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 January 2, 2023, to January 19, 2023
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377) and a 
custom seat cushion (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics and a custom seat cushion. You say that these 
items are medically necessary. The Plan denied your request. The Plan says the requested items are 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 upgraded electronics and a custom 
seat cushion. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that you have adequate strength to manage the standard 
power drive controls. The upgraded electronics are not medically necessary to meet your mobility needs. The 
requested seat cushion is unbundled from the approved power tilt and recline and is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the upgraded electronics and a custom seat cushion have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, 
E2377) and a custom seat cushion (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing billed with code G0481 for dates of service 
March 8, 2022, and June 8, 2022. 
 
You asked the Plan to pay for code G0841. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed an incorrect code for this service. 
 
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 drug testing, definitive 8-14 classes. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, you billed a drug testing 
code that is only applicable when 8-14 classes of drugs are tested.  In this case, the records show that 29 drug 
classes were tested.  As a result, a different code (i.e., G0843) should have been billed to reflect the number of 
drug classes actually tested. Based on this information, we decided that Medicare rules for coverage of code G0841 have not been met. Therefore, we decided that the Plan does not have to pay for drug testing billed with 
code G0481 for dates of service March 8, 2022, and June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 7, 2023. 
 
You asked the Plan to pay for the medical services. You say that you billed this claim with valid diagnosis 
codes. The Plan denied your request. The Plan says you billed these services with an inappropriate pair of 
diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of R31.1 and N30.01. Code N30.01 is an Excludes1 code 
under code R31.1, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on February 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the requested treatment is considered 
safe and effective, as supported by its clinical benefits to patients, continued medical professional adoption, and 
strong clinical evidence with numerous peer-reviewed studies.  The Plan denied your request. The Plan says 
there are not enough studies to show that use of the Vertiflex Superion device is better than regular spine 
surgery for the enrollee's problem or that it will help in their care.  
 
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 Vertiflex procedure. Our reviewer 
says that the Vertiflex procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex procedure is experimental. More research is 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 the Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair and associated sales tax purchased on 
July 15, 2022. 
 
You asked the Plan to pay for the power wheelchair and sales tax. You say that you do not believe the Plan 
ever intended to pay its share of this chair. The Plan denied your request. The Plan says you have not provided 
all of the documentation needed to support criteria have been met for a power mobility device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD are not covered unless you have undergone a 
face-to-face evaluation to determine the need for the specific chair provided, AND if you have had a home 
assessment to determine that the chair meets your needs in the home. 
 
In this case, there is no evidence that any such face-to-face encounter occurred or that you have had the 
required home assessment.  As such, neither the chair nor the associated sales tax can be covered. 
 This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan 
does not have to pay for the power wheelchair and associated sales tax purchased on July 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) Respiratory Pathogen 
panel you provided on February 3, 2023. 
 
You asked the Plan to pay for the PCR Respiratory Pathogen Panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or 
more pathogens are non-covered.  In this case, the lab report show that more than 6 pathogens were tested in 
this panel, making this service non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PCR Respiratory Pathogen Panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the polymerase chain reaction (PCR) Respiratory Pathogen panel you provided on February 
3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says  an IRF admission is 
not medically necessary, and the enrollee's needs can be met at an alternate level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair you purchased on February 9, 2023. 
 
You asked the Plan to pay for the lift chair. You say that you were under the impression that you could use any 
provider and get reimbursed. The Plan denied your request. The Plan says it cannot pay for items provided by a 
non-Medicare certified equipment provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider who supplied the lift chair is not enrolled in 
the Medicare program. Therefore, we decided that the Plan does not have to pay for the lift chair you purchased 
on February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that this is a Medicare-allowed code. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 8, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90853 billed for date of service December 6, 
2022, to January 25, 2023.  
 You asked the Plan to pay for procedure code 90853. You say that these services should have been fully 
covered by insurance. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 90853 is 1. The MAI value for this code is 3. The provider in this case 
billed 7 units of this code per day, exceeding the MUE. The provider has not provided all the required evidence 
showing that the excess units were actually provided, were correctly coded, and were medically necessary. 
Based on this information, we decided that Medicare rules for coverage of procedure code 90853 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 90853 billed for date of 
service December 6, 2022, to January 25, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided by a Licensed 
Clinical Social Worker on February 20, 2022. 
 You asked the Plan to pay for the outpatient mental health services. You say that you have provided medical 
records so this claim can be paid. The Plan denied your request. The Plan says there is no evidence that this 
provider attempted to consult with the patient's primary care doctor. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for outpatient mental health 
services provided by a Licensed Clinical Social Worker on February 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genomic sequencing services billed for date of service 
November 29, 2022. 
 
You asked the Plan to pay for the genomic sequencing services. You say that this course of treatment is prudent 
and necessary in order to treat the patient, The Plan denied your request. The Plan says you did not provide any 
records from the referring provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician who orders the service must 
maintain documentation of medical necessity in the beneficiary's medical record. 
 
In this case, the doctor who ordered this testing is not located anywhere within the medical records provided.  
There are no medical records from the ordering provider, so it is not clear why, exactly, this provider ordered 
this testing.  Medicare requires records to substantiate that the provider who ordered the testing is treating the patient.  Without such records, we cannot determine if Medicare criteria for coverage have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genomic sequencing services have not been met. Therefore, we decided that the Plan does not 
have to pay for genomic sequencing services billed for date of service November 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99282 billed for date of service November 
23, 2022. 
 You asked the Plan to pay for procedure code 99282. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99282 is bundled into payment for code 99285. 
 
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 99282 
is a column II code to column I code 99285. 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 code 99282 billed for date of service November 23, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0675 for dates of service October 4, 2022, to October 21, 2022 
 
You asked the Plan to pay for the PCD. You say that this item is medically necessary based on medical 
literature showing the efficacy for the patient's condition. The Plan denied your request. The Plan says this 
device is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that PCDs billed with code E0675 will be denied as 
not reasonable and necessary. 
 
You billed the PCD in question with code E0675, so there is no coverage for this item. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PCD have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code E0675 for dates of service October 4, 2022, to October 
21, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from February 1, 2023, to 
March 8, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you do not understand how these standard 
services can be denied. The Plan denied your request. The Plan says these services are not covered when 
performed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulations of the spine. Therefore, we decided 
that the Plan does not have to pay for chiropractic services provided from February 1, 2023, to March 8, 2023.