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

 
We decided that the Plan does not have to pay for the genetic testing provided on November 29, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you are requesting reconsideration of the denied 
claim. 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 the genetic testing 
provided on November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous airway pressure (CPAP) device and supplies 
(E0601, A4604, A7013, A7034) purchased August 11, 2023. 
 
You asked the Plan to pay for the CPAP device and supplies. You say that your machine died after over a 
decade of use. You shopped online for the lowest price and purchased a replacement. You should not be 
penalized for this. The Plan denied your request. The Plan says the items was purchased from a supplier who 
does not participate and is not certified with Medicare. 
 
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 at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous airway pressure (CPAP) 
device and supplies (E0601, A4604, A7013, A7034) purchased August 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay  a pneumatic compression device (E0675) provided April 17, 
2023, to April 24, 2023. 
 
You asked the Plan to pay  a pneumatic compression device. You say that you are requesting reconsideration 
based on medical necessity for this enrollee and evidence based medical literature that substantiate the efficacy 
of the treatment rendered. The Plan denied your request. The Plan says a PCD coded s E0675 will be denied as 
not reasonable and necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
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. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay  a pneumatic compression device (E0675) provided April 17, 2023, to April 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87481, 87491, 87500, 87653, 87563, 
87640, 87641 and 87798) billed for date of service May 16, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (87481, 87491, 87500, 87653, 87563, 87640, 87641 and 
87798) billed for date of service May 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 need IRF services to get stronger so you can do 
more for yourself at home. The Plan denied your request. The Plan says you do not meet the requirements for 
an IRF admission.  
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation program provided in an 
IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87481, 87500, 87640 and 87652) billed 
for date of service January 24, 2022. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (87481, 87500, 87640 and 87652) billed for date of service 
January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) provided on July 18, 2023. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed 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 or must reach 45-59 minutes of total time. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the office visit. Our reviewer says that the records do not 
support the code billed. Our reviewer found the records show this is a repeat visit and not a new patient visit.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an office visit (99204) provided on July 18, 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 the enrollee would greatly benefit from daily 
assistance and would be able to resume doing normal activities. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria for inpatient rehabilitation facility services.  
 
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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87481, 87491, 87563, 87640, 87653, 
87798, 87641 and 87500) billed for date of service June 27, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (87481, 87491, 87563, 87640, 87653, 87798, 87641 and 
87500) billed for date of service June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis-adult (D1110), bitewing x-rays (D0274) and a 
periodic oral evaluation (D0120) provided on May 4, 2023 by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network dental services. You say that you feel the services should be 
covered as you were not aware the dentist was no longer in network. The Plan denied your request. The Plan 
says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a prophylaxis-adult (D1110), bitewing x-rays (D0274) and a periodic oral evaluation (D0120) 
provided on May 4, 2023 by an out-of-network provider.
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 need this care. The Plan denied your request. 
The Plan says your condition does not meet the criteria for an IRF admission.  
 
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 your medical, rehabilitation, and nursing needs does not require 
IRF care with an interdisciplinary approach to rehabilitative care. Your rehabilitation needs can be safely 
provided in an alternate 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 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: 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 the enrollee needs IRF services to recover to the 
fullest extent and be discharged to a community setting, averting unplanned readmissions. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
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 enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation program provided in an IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223, & 99233 provided on February 16, 
2023 to February 17, 2023. 
 
You asked the Plan to pay for procedure codes 99223, & 99233. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the records do not support the billed services. 
 
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 codes 99223, & 99233 are initial hospital care requiring high 
level decision making or 75 minutes total time, and subsequent hospital care requiring high level decision 
making or 50 minutes total time. 
 
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 codes 99223, & 99233. Our reviewer says that the billed codes are not supported by the records. Our reviewer found the records do not document the duration of 
these services, and the records do not support medical decision making of high complexity. 
 
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 codes 99223, & 99233 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 99223, & 99233 provided on February 16, 2023 to February 
17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63045, 22842, 63048, and 22853 billed for 
date of service May 26, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says there is 
insufficient documentation to corroborate the services. 
 
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 63045 is laminectomy, facetectomy and foraminotomy 
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or 
lateral recess stenosis]), single vertebral segment; cervical. We find that there is a more applicable code that 
describes the cervical arthrodesis procedure provided. Additionally, we have confirmed that codes 2282, 
63048, and 22853 are add-on codes to primary procedure code 63045. Because the primary procedure code is 
not payable in this case, the add-on codes are also not payable. 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 codes 63045, 22842, 63048, and 22853 billed for date of service May 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination (x-ray) (73562) of the knee 
provided on May 22, 2023. 
 
You asked the Plan to pay for the x-ray. You say that 73562 was billed correctly and should be paid. The Plan 
denied your request. The Plan says code 73562 cannot be billed separately because it is packaged into payment 
for CPT code 99283. 
 
We find that CPT code 73562 has a status indicator of Q1 in the Outpatient Prospective Payment System 
(OPPS). Q1 codes are packaged and are not separately paid when billed with another code with an OPPS 
indicator of S, T, or V. In this case, code 99283 that was billed and paid on the same date of service has a status 
of J2 and V. Therefore, code 73562 is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have 
to pay for the radiologic examination (x-ray) (73562) of the knee provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning including the explanation and a home 
or residence visit for the evaluation provided on June 02, 2023. 
 
You asked the Plan to pay for advance care planning including the explanation and a home or residence visit 
for the evaluation. You say that this service is supported in the records proving medical necessity. 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 advance care planning 
including the explanation and a home or residence visit for the evaluation provided on June 02, 2023.