Persius/hicric huggingface dataset:
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 November 
19, 2022.  
 
You asked the Plan to pay for procedure code 99232. You say that this was a separate procedure and should be 
paid. The Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 
00790-QK. 
 
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 00790-QK 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 November 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 24, 2021. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
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 laboratory services was not filed until May 12, 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 the laboratory services provided on December 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 10, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the enrollee's health Plan is Medicare. The Plan 
denied your request. The Plan says they have determined that the services rendered to the enrollee are not 
urgent or emergent, nor were they approved in advanced by a network provider. 
 
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 an office visit provided on April 10, 2023, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 3, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E2311, E2313, E2377, E0955, E1007, 
E1012, E1028, E2300, E2323, E2359, E2607, and E2620). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair with multiple power options and 
additional items and accessories. You say that you would like the documentation to be reconsidered for the 
K0861 base and all recommended components, needed to meet the enrollee's current medical, mobility, and 
functional needs. The Plan denied your request. The Plan says the enrollee does not have medical need for 
multiple power options included with a K0861 Group 3 power wheelchair. The Plan also says an electronic 
connection, expandable controller, and expandable controller harness cannot be covered as it is not medically 
necessary to control the three requested power options through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
met. The rules also say if the PWC base is not covered, then related accessories will be denied. 
 
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 Group 3 standard power wheelchair 
with multiple power options and additional items and accessories. Our reviewer says that the enrollee does not 
meet the criteria for coverage. Our physician reviewer found the enrollee has intact skin and is continent. The 
enrollee does not have high risk for skin breakdown or use intermittent catheterization. nor have spasticity. Our 
reviewer also found that the enrollee has sufficient strength and function in their upper extremities to manage 
standard power drives. 
 
 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 Group 3 standard power wheelchair with multiple power options and 
additional items and accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Group 3 standard power wheelchair with multiple power options (K0861) and additional items and 
accessories (codes E2311, E2313, E2377, E0955, E1007, E1012, E1028, E2300, E2323, E2359, E2607, and 
E2620).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 0334U billed for date of service January 28, 2023. 
 
You asked the Plan to pay for procedure code 0334U. You say that  this test was necessary and was reported 
appropriately. The Plan denied your request. The Plan says that this code is not supported in the records 
provided. 
 
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 0334U is oncology (solid organ), targeted genomic sequence analysis, formalin-fixed paraffin-embedded 
(FFPE) tumor tissue, DNA analysis, 84 or more genes, interrogation for sequence variants, gene copy number 
amplifications, gene rearrangements, microsatellite instability and tumor mutational burden. 
 
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 procedure code 0334U. Our reviewer says that this code is 
supported. Our reviewer found the records document a signed order for, and results of a Guardant 360 Tissue 
Next analysis of 84 cancer-associated genes, gene rearrangements, microsatellite instability and tumor 
mutational burden of formalin-fixed paraffin-embedded (FFPE) tumor tissue for a patient with advanced clear 
cell renal cancer reported for the date in question. The service is supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 0334U have been met. Therefore, we decided that the Plan has 
to pay for procedure code 0334U billed for date of service January 28, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Aortopathy Comprehensive Panel (81410, 81411) 
provided on April 5, 2023. 
 
You asked the Plan to pay for the Invitae Aortopathy Comprehensive Panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says these are non-covered codes. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 81410 and 81411 will be denied 
automatically as not medically necessary. 
 
We looked at the file and Medicare rules. The code at issue is not covered. Based on this information, we 
decided that Medicare rules for coverage of the Invitae Aortopathy Comprehensive Panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the Invitae Aortopathy Comprehensive Panel 
(81410, 81411) provided on April 5, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110, 97112, 97140, and 97530 for date of 
service January 22, 2023, to January 25, 2023. 
 
You asked the Plan to pay for procedure codes 97110, 97112, 97140, and 97530. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the submitted medical records do not 
include a plan of care. 
 
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 codes 97110, 97112, 97140, and 97530 are not payable as billed. Specifically, the 
documentation submitted did not include a plan of care. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 97110, 97112, 97140, and 97530 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 97110, 97112, 97140, and 97530 for date of 
service January 22, 2023, to January 25, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 You asked the Plan to pre-approve the therapy services. You say that the enrollee has made progress and 
requires continued therapy to reach treatment goals. The Plan denied your request. The Plan says the requested 
services are not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the member has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
members medical condition and therefore are 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy (PT) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not have any objective evidence of unstable 
conditions requiring physician oversight. The Plan says that the services needed may be provided safely in 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 4, 2023, billed with 
procedure code 99443. 
 
You asked the Plan to pay for practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this service is bundled into procedure code 99215, 
provided on April 27, 2023. 
 
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 99443 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion. 
 
We find that CPT code 99443 is not supported in the medical record. Specifically, documentation shows that 
this service was provided within 7 days of procedure code 99215 and is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of practitioner services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for practitioner services provided on May 4, 2023, 
billed with procedure code 99443.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for date of service March 1, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the level of service 
billed. The Plan denied your request. The Plan says the code is not supported.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
 We asked our physician 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 billed services. Our reviewer found that the enrollee 
was seen for epistaxis and audiology services. The documentation supports an appropriate exam, but not an 
appropriate history or medical decision making of moderate level. Therefore, the documentation does not 
support the billed code. 
 
We looked at this physicians review, the file, and Medicare rules. 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 99204 billed for date of service March 1, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a single epidural steroid injection. We decided that the Plan does 
not have to pre-approve an additional epidural steroid injection.  
 
You asked the Plan to pre-approve epidural steroid injections. You say that you have had multiple surgeries 
resulting in a titanium disc in your lower back. The Plan says that an epidural steroid injection is not medically 
necessary. 
 
We decided that the Plan has to pre-approve a single epidural steroid injection and does not have to pre-
approve the additional injection. 
 
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 injection. Our reviewer says that a 
single epidural steroid injection is medically necessary. Our physician reviewer found that the enrollee has 
spinal stenosis and degenerative disc disease which are indication for an epidural steroid injection. However, 
the request is for an interlaminar approach not transforaminal. Therefore, only a single epidural steroid 
injection is medically reasonable and 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 injections have not been met. Therefore, we decided that the Plan does have 
to pre-approve an epidural steroid injection and not an additional epidural steroid injection. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional visits are medically 
necessary. The Plan denied your request. The Plan says the requested services are not medically reasonable and 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the member has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
members medical condition and therefore are 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy (PT) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 gene (prothrombin coagulation factor II) and F5 
gene (coagulation factor V). 
 You asked the Plan to pre-approve F2 gene and F5 gene. 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 molecular pathology procedures (Tier1 and Tier 2) 
may be eligible for coverage when certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve F2 gene and F5 gene. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the F2 and F5 genetic tests are 
not considered to be clinically efficacious. Therefore, testing is not medically necessary. The review indicates 
that the enrollee does not meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of F2 gene and F5 gene have not been met. Therefore, we decided that the Plan 
does not have to pre-approve F2 gene (prothrombin coagulation factor II) and F5 gene (coagulation factor V).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that this service should be unlimited. The Plan 
denied your request. The Plan says the evidence shows you have used eighteen (18) one-way trips of the (18), 
one-way trips covered by your health plan for the year 2023. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 18 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional routine transportation trips (A0100).