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

 
We decided that the Plan does not have to pay for procedure code 49000 billed for date of service October 31, 
2022.  
 
You asked the Plan to pay for procedure code 49000. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 49000 is bundled into payment for code 44602. 
 
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 49000 
is a column II code to column I code 44602 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 49000 billed for date of service October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99204, 74230, 74240, 72040, 70100, and 70310 for 
date of service January 11, 2023. 
 
You asked the Plan to pay for codes 99204, 74230, 74240, 72040, 70100, and 70310. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT codes 99204, 74230, 74240, 72040, 70100, and 70310 are not payable as billed. Specifically, 
these services were billed with a place of service 11 (office). The documentation received does not support that 
the place of service billed as the services were provided in a mobile setting at a skilled nursing facility. Based 
on this information, we decided that Medicare rules for coverage of codes 99204, 74230, 74240, 72040, 70100, 
and 70310 have not been met. Therefore, we decided that the Plan does not have to pay for codes 99204, 
74230, 74240, 72040, 70100, and 70310 for date of service January 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 10, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 99153 billed for date of service September 
1, 2022. 
 
You asked the Plan to pay for procedure code(s) 99153. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this code is included in the facility payment and 
is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 99153. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 99153. Based on this information, 
we decided that Medicare rules for coverage of procedure code 99153 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 99153 billed for date of service September 1, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27054-59-AS billed for date of service 
September 20, 2022. 
 
You asked the Plan to pay for procedure code 27054-59-AS. You say that the documentation justifies the 
billing. The Plan denied your request. The Plan says payment for code 27054-59-AS is bundled into payment 
for code 27130. 
 
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 27054-59-AS is a column II code to column I code 27130. The 
medical records provided do not show that the service billed with the -59 modifier was a distinct procedural 
service. 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 27054-59-AS billed for date of service September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 87481 billed with diagnosis N30.81 (Other cystitis with 
hematuria) for date of service March 14, 2023. 
 
You asked the Plan to pay for code 87481 billed with diagnosis N30.81. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the coding was inappropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for code 87481 billed with diagnosis N30.81. Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee cystitis with hematuria, nonspecific urethritis, and straining to 
void. Testing was ordered including code 87481; however, the limited documentation provided did not clearly 
explain why PCR testing for candida was clinically appropriate in this case. There was no indication this 
testing would have been more effective and appropriate than standard of care testing for fungal UTI (culture, 
KOH, etc.). Therefore, the enrollee did not meet criteria for the services billed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87481 billed with diagnosis N30.81 have not been met. Therefore, we 
decided that the Plan does not have to pay for code 87481 billed with diagnosis N30.81 (Other cystitis with 
hematuria) for date of service March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service January 20, 
2023. 
 
You asked the Plan to pay for procedure code 99070. The Plan denied your request. The Plan says procedure 
code 99070 is considered bundled and not separately payable.  
 
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 code 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99070 billed for date of service January 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this procedure will address the 
enrollee's symptoms of lower back pain. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found MRI shows facet joint disease and foraminal narrowing. The cause of back pain is 
not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided on February 4, 2023, by an OON 
provider.  
 
You asked the Plan to pay for home health care. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 home health care provided on February 4, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on November 14, 2022, to 
November 23, 2022, billed with code 97026. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
has determined that there is sufficient evidence to conclude the use of infrared therapy devices and any related 
accessories is not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act (the Act).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. This claim was billed with procedure code 
97026 which is a non-covered service. Therefore, we decided that the Plan does not have to pay for practitioner 
services provided on November 14, 2022, to November 23, 2022, billed with code 97026.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision supply provided on March 13, 2023. 
 
You asked the Plan to pay for the vision supply. You say that your contract says that eyewear is a covered 
benefit. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the vision supply have not been met. Therefore, 
we decided that the Plan does not have to pay for the vision supply provided on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service April 21, 2021. Therefore, we decided that the Plan does not have to pay for a crown on tooth 30 provided on March 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your medical and therapy teams have recommended 
admission to an IRF. You also say you cannot go home because you have no one who can care for you. The 
Plan denied your request. The Plan says you do 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 that 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 you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on March 18, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the emergency services should be 
covered. The Plan denied your request. The Plan says the inpatient level of care was not medically necessary. 
The Plan also says that the service was not authorized. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the provided documentation indicates the enrollee was not taking their medication as 
prescribed. The reviewer found that the enrollee was afebrile without signs of serious infection. There was no 
seizure activity was observed and the enrollee's vitals were stable. The admitting physician did not expect the 
enrollee would require hospital services that would likely cross 2 midnights as the enrollee was stable and 
treatment plan was not complex. Therefore, the reviewer found that the inpatient admission was not medically 
reasonable or 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve a routine transportation trip for a total of 64 miles. 
 
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the request exceeds the benefit limit. 
 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 routine transportation for 24 one-way trips per year and each one-way trip must not 
exceed 50 miles. 
 
We looked at your request, the records in the case file, and the rules. The requested trip is for a total of 64 
miles, which is 14 miles beyond the 50-mile limit for a one-way trip. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to approve a routine transportation trip for a total of 64 miles.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81279, 81338). 
 
You asked the Plan to pre-approve genetic testing. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the records do not show that you have 
documentation of the negative JAK2V617F testing that is required in the step-by-step (sequential) testing per 
the Medicare rules. The request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found provided records in this case do not document genetic testing impacts medical management; 
and the enrollee would meet WHO's diagnostic criteria for PV, if JAK2 exon 12 testing were positive; and 
JAK2 V617F mutation analysis was previously completed and was negative. Provided records in this case do 
not document the genetic testing impacts medical management; and JAK2 V617F mutation analysis was 
previously completed and negative; and the enrollee would meet WHO's diagnostic criteria for MPD if a clonal 
marker were identified as required by the Local Coverage Determination (LCD) MolDX: Genetic Testing for 
BCR-ABL Negative Myeloproliferative Disease L36815. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81279, 81338).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary for the enrollee. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Restasis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CX Bladder Triage test provided on July 13, 2022.  
 
You asked the Plan to pay for the CX Bladder Triage test. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the CX Bladder panel remains unproven at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the CX Bladder Triage test. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the CX Bladder Triage test has not been clinically validated by the MolDX Program and documented in the DEX Diagnostics Registry. The review has determined that the items/services 
at issue in this case are not medically reasonable or 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 CX Bladder Triage test have not been met. Therefore, we decided that the 
Plan does not have to pay for the CX Bladder Triage test provided on July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies coded as A6223, A6220 and A6021 
provided February 10, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that the enrollee has been treated for their 
wounds and billing separately for these supplies is appropriate. The Plan denied your request. The Plan says the 
services provided are not separately billable and should be consolidated with the enrollee's inpatient skilled 
nursing facility stay. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wound care supplies were used in a SNF or hospital. Therefore, we decided that the Plan 
does not have to pay for the wound care supplies coded as A6223, A6220 and A6021 provided February 10, 
2023.