Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye refraction (92015). 
 
You asked the Plan to pre-approve an eye refraction. You say that this requested service is part of the refraction 
surgery that you will need. The Plan denied your request. The Plan says an eye refraction cannot be billed 
separately, regardless of whether the refraction is performed during a routine eye examination or incidental to a 
medical eye examination. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is performed as a routine screening by a participating 
provider. 
 
We looked at the file and the Plan's rules. Specifically, an eye refraction is only covered by the Plan when it is 
performed as part of a routine screening by a participating provider. Refractions cannot be billed separately. 
Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an eye refraction (92015).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 0241U billed for date of service December 22, 2022. 
 
You asked the Plan to pay for code 0241U. You say that this claim should be reconsidered. 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 code 0241U have not 
been met. Therefore, we decided that the Plan does not have to pay for code 0241U billed for date of service 
December 22, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided October 14, 2022, to October 
17, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that an inpatient admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided October 14, 2022, to October 17, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99204-25 billed for date of service July 28, 2022. 
 
You asked the Plan to pay for code 99204-25. You say that this service was billed with the -25 modifier, 
indicating that it is unbundled from code 93000. The Plan denied your request. The Plan says that this charge is 
incidental to another service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial is that this charge is incidental to 
another service.  However, the Plan has failed to identify what that other service was.  We can infer from the 
billing records that the other service is code 93000.  However, you did bill code 99204 with the -25 modifier, 
which indicates it is separate and distinct from code 93000.  The Plan has failed to comment on whether or not 
it determined that the -25 modifier was appended inappropriately.  In fact, the Plan has failed to provide any 
explanation at all for apparently ignoring the billing of this modifier. The burden is on the Plan to show why its 
denial is appropriate.  By failing to address the billed modifier (that would make code 99204 separately payable 
from 93000), we find that the Plan has not met this burden. Therefore, we decided that the Plan has to pay for 
code 99204-25 billed for date of service July 28, 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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided on July 19, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the patient was transported from the 
hospital to their home on this date of service, so separate payment should be made for these ambulance 
services. The Plan denied your request. The Plan says that this service was inappropriately coded based on 
standard coding guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial is that this service was coded 
inappropriately.  However, the Plan has failed to provide any explanation as to what they believe is wrong with 
the coding.  Further, the Plan has failed to provide a citation to any rule or guideline upon which this rationale 
was based.  The burden is on the Plan to show why its denial was appropriate.  By failing to provide any of this 
background information, we find that the Plan has not met this burden. Therefore, we decided that the Plan has 
to pay for ambulance services provided on July 19, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam therapy (PBT) (77470, 77523, G6002). 
 
You asked the Plan to pre-approve PBT. You say that the treatment is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says that the enrollee does not meet criteria for approval of 
the requested treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 PBT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of proton therapy is an accepted radiation technology, that has proven efficacy and 
tolerability. It is therefore not investigational, as it is simply another means to deliver radiation.  Certain 
conditions such as base of skull chordomas and chondrosarcomas, and pediatric CNS malignancies are 
probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the 
tumor, while relatively sparing the neighboring normal tissue. There is abundant data on proton therapy for 
sinonasal cancers as well, and proton therapy is an accepted treatment modality. Proton therapy is not 
experimental, but rather is simply another means if delivering radiation, and has been in use for the treatment 
of oncology enrollees for decades. There are dosimetric advantages to using proton therapy over IMRT in 
select situations, in which proton therapy offers a clinically meaningful benefit. For this enrollee, there is no 
plausible reason for why IMRT would be unacceptable or that proton therapy would offer a plausible clinically 
meaningful benefit over standard of care IMRT. The decision is therefore favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT have been met. Therefore, we decided that the Plan has to pre-approve 
proton beam therapy (PBT) (77470, 77523, G6002).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided May 16, 2022, by an out of 
network provider. 
 
You asked the Plan to pay for the dental services. You say that please review the following medical records to 
reconsider the denied codes for medical necessity. You believe these services were appropriate based on past 
medical history. The Plan denied your request. The Plan says the services are not eligible for coverage under 
the medical benefit. 
 
 Medicare generally does not cover dental services. The Plan follows the same rule. 
 
Dental services provided in an outpatient hospital setting are not covered under medical or dental benefits. The 
services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the 
enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are not 
covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental 
services provided May 16, 2022, by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36005 billed for date of service October 3, 
2022. 
 You asked the Plan to pay for procedure code 36005. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 36005 is bundled into payment for 
code 75827. 
 
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 36005 
is a column II code to column I code 75827. 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 36005 billed for date of service October 3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medical services billed with codes 99214 and G9744 for date of 
service March 23, 2022. 
 
You asked the Plan to pay for the medical services. You say that the provider of these services is an internal 
medicine physician.  They are permitted to bill these codes. The Plan denied your request. The Plan says that 
Evaluation and Management codes are not covered for this specialty or provider type. 
Please bill with appropriate codes. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial is "Evaluation and Management 
codes are not covered for this specialty or provider type. Please bill with appropriate codes."  However, the 
Plan has provided absolutely no support for this assertion. They have provided no citation to any rule upon 
which this decision is based.  The Plan has provided no proof of what type of provider they believe the billing 
provider is, or proof that the provider type they believe the billing provider is is ineligible to bill these codes.  
The scant case file submitted by the Plan lacks any detail supporting its denial rationale. Therefore, we decided 
that the Plan has to pay for the medical services billed with codes 99214 and G9744 for date of service March 
23, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the regional nerve block described by code 64488. We decided that 
the Plan does not have to pay for the 141 units of code 00790.  
 
You asked the Plan to pay for the anesthesia services and regional nerve block provided on January 11, 2022, 
billed with 141 units of code 00790 and one unit of code 64488.. You say that these services are for the 
supervising anesthesiologist which should be paid in addition to the Certified Registered Nurse Anesthetist 
(CRNA) services. The Plan says that the number of units of code 00790 cannot be verified. In addition since 
there is a correct coding conflict between 00790 and 64488, the component code 64488 cannot be reviewed. 
 
We decided that the Plan has to pay for the regional nerve block described by code 64488.  
 
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 64488 is Transversus abdominis plane (TAP) block 
(abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when 
performed). 
 
The file shows that the above described nerve block was performed and was separate and distinct from the 
general anesthesia, as it was documented to be done for postoperative pain control. Though there is an edit 
between the two billed codes, modifier -59 was correct used to indicate this was a distinct procedural service. 
Therefore, we decided that the Plan has to pay for the regional nerve block described by code 64488.  
 
We also decided that the Plan does not have to pay for the 141 units of code 00790. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
For anesthesia codes, the number of units reported refers to the time in minutes that anesthesia care was 
provided. We reviewed the anesthesia report and confirmed that it does not support that care was provided for 
141 minutes. Therefore, we decided that the Plan does not have to pay for the 141 units of code 00790. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 19, 
2022. 
 You asked the Plan to pay for procedure code 0003A. You say that this claim should be paid in accordance 
with Medicare payment rules. 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 0003A 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 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a DecisionDx-SCC test (0315U) provided on November 8, 
2022. 
 
You asked the Plan to pay for laboratory testing. You say that you disagree with the denial and request 
reconsideration of payment on this claim. The Plan denied your request. The Plan says the documentation 
indicates that the requested test is an example of services that are not relevant to a Medicare beneficiary, are not 
considered a Medicare benefit (statutorily excluded), and therefore will be denied as a Medicare excluded test. 
 
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 documentation fails to indicate that the test has not been 
validated in peer reviewed medical literature. The Local Coverage Article confirms that the requested test is not 
considered a Medicare benefit. Based on this information, we decided that Medicare rules for coverage of 
laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for a 
DecisionDx-SCC test (0315U) provided on November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service July 15, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this was billed with the correct place of 
service and should be paid. The Plan denied your request. The Plan says code 99153 is not payable in the 
facility setting. 
 Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service July 15, 2022, billed with 
code 99153.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 8, 2022, to 
May 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 8, 2022, to 
May 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on December 21, 2022. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
December 21, 2022.