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

 
We decided that the Plan does not have to pay for the laboratory services billed with code 84702 on January 24, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that any diagnosis code not listed for Human 
Chorionic Gonadotropin does not support medical necessity. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with diagnosis codes N52.9 
and N50.9. These diagnosis codes are not listed as supporting medical necessity; therefore, the testing cannot 
be supported. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with 
code 84702 on January 24, 2023.
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 still unable to walk and need more time to 
accomplish goals. The Plan denied your request. The Plan says the SNF services you are requested no longer 
meet the requirements for approval. 
 
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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73700 and 76140 billed for date of service 
December 21, 2022. 
 You asked the Plan to pay for procedure codes 73700 and 76140. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the claim for procedure code 73700 is a duplicate 
of a previously paid claim and was correctly denied. The billed code 76140 is invalid for Medicare purposes. 
 
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. The rules 
also say that providers must report services correctly. Providers must report services with the appropriate 
procedure code. 
 
We looked at the file and Medicare rules. The file includes evidence that procedure code 73700 was 
reimbursed by the Plan on January 24, 2023. Comparison of the two claim lines shows these are exact 
duplicates. There is no evidence presented to support that the services denoted by procedure code 73700 were 
provided twice on the same date. Based on this information, we decided that the Medicare rules for procedure 
codes 73700 have not been met. Furthermore, we find that procedure code 76140 has a Status Indicator of I on 
the Physician Fee Schedule. This means that procedure code 76140 is not valid for Medicare purposes. Based 
on this information, we decided that Medicare rules for coverage of procedure code 76140 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 73700 and 76140 billed for date 
of service December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes H2035, H0001, and H2036 billed for date of 
service March 23, 2022 to September 22, 2022. 
 
You asked the Plan to pay for procedure code H2035, H0001, and H2036. You say that this should be paid for. 
The Plan denied your request. The Plan says the billed codes are 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 codes H2035, H0001, and H2036 have a Status Indicator of I on the Physician Fee 
Schedule. This means that these codes are not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of procedure code H2035, H0001, and H2036 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes H2035, H0001, and H2036 billed 
for date of service March 23, 2022 to September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service January 16, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that you would like the Plan to reconsider their 
denial of payment. 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 88341 is 13. The MAI value for this code is 3. You billed 29 units of this 
code, exceeding the MUE. You did not provide 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service January 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The clinical 
documentation shows that the enrollee requires ongoing skilled physical and occupational therapy however, it 
does not show that the enrollee requires or would tolerate an intensive rehabilitation program. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are a fall risk with zero mobility and require 
additional SNF services. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that 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 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 continuation of SNF care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on August 22, 2022, by 
a non-network provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-network provider without 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 the psychotherapy services provided on August 
22, 2022, by a non-network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 25, 2022, to 
February 23, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the RAP on time, and the 
NOA afterward. 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 25, 2022. The NOA was not received by the Plan until April 1, 
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 the home health services 
provided from January 25, 2022, to February 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176-26-GC billed for date of service 
February 13, 2023. 
 You asked the Plan to pay for procedure code 74176-26-GC. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for code 74176 is bundled into payment 
for code 74177. 
 
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 74176 
is a column II code to column I code 74177. 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 74176-26-GC billed for date of service February 
13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (code 99233) provided on February 
17, 2023. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollee was an outpatient at the time of this service, but an 
inpatient POS code was used. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and POS code. 
 
In this case, the POS code on the claim is 21, which indicates inpatient hospital services. However, the records show that the enrollee was considered outpatient on the date of service. Based on this information, we decided 
that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the 
Plan does not have to pay for the physician services (code 99233) provided on February 17, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that this medication is medically necessary. The Plan denied 
your request. The Plan says the step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
coverage criteria has not been met. The Plan requires you have either a history of osteoporosis-related fracture 
or has completed a trial of zoledronic acid before they will approve the requested drug. Our physician reviewer 
found that there is no documentation of an osteoporotic fracture and you have not tried and failed the required 
drug, zoledronic acid. There is also no documentation provided indicating that the Plan's required drug would 
likely be less effective and/or likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 5, 2022, to 
February 3, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the RAP timely and 
submitted the NOA afterward. 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 5, 2022. The NOA was not received by the Plan until February 5, 
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 the home health services 
provided from January 5, 2022, to February 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mobile shower. 
 
You asked the Plan to pre-approve a mobile shower. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a mobile shower may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a mobile shower.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99217) provided on January 11, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed cannot be paid. 
 
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 99217 is not supported in the medical record. Specifically, per Local Coverage Article 
A52985  Billing and Coding: Acute Care: Inpatient, Observation and Treatment Room Services, code 99217 
is no longer listed as a covered Group 1 code. Based on this information, we decided that Medicare rules for 
coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay 
for physician services (99217) provided on January 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (U0004, U0005, G2023) provided on March 9, 
2021. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab testing was not filed until February 2, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for lab testing (U0004, U0005, G2023) provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical-care services (99291) provided on September 24, 
2022. 
 
You asked the Plan to pay for critical-care services. 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 the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (36620) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for critical-care services (99291) provided on September 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88104 billed for date of service December 
30, 2022. 
 You asked the Plan to pay for procedure code 88104. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 88104 is bundled into payment for code 88112. 
 
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 88104 
is a column II code to column I code 88112. 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 88104 billed for date of service December 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service January 27, 
2023.  
 
You asked the Plan to pay for procedure code 99232. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99232 is bundled into payment for code 99223. 
 
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 99232 
is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99232 billed for date of service January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 27, 
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 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 10, 2022, to 
July 6, 2022. 
 You asked the Plan to pay for the home health services. You say that the claim should not be fully denied.  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 May 11, 2022. The NOA was not received by the Plan until August 19, 
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 the home health services 
provided from June 10, 2022, to July 6, 2022.