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

 
We decided that the Plan does not have to pre-approve an inpatient placement of an osseo-anchored prosthesis 
 
You asked the Plan to pre-approve an osseo-anchored prosthesis. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 osseo-anchored prosthesis. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case.  
Our physician reviewer found that there is limited published, large-scale, long-term, peer-reviewed literature 
that shows the requested osseo-anchored prosthesis to be an effective and/or safe treatment for the enrollee's 
pathology. Further studies are needed to corroborate the safety and efficacy of the requested prosthesis. No compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 osseo-anchored prosthesis have not been met. Because criteria for the base 
services have not been met, inpatient admission also cannot be approved. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient placement of an osseo-anchored prosthesis
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on September 14, 2021. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says medical records have not been provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the imaging services provided have been met. Specifically, complete medical records for this date of service have not been provided for review. 
Therefore, we decided that the Plan does not have to pay for imaging services provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the dermatology service provided on November 2, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to reimburse you for the dermatology service. You say that you have a mole on your neck 
which has changed shape and color recently. You say that the provider advised it should be removed. You also 
say that the office confirmed that the provider was in-network. The Plan denied your request. The Plan says 
prior authorization was not obtained. 
 
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 reimburse you for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
The 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 reimburse you for these 
items/services. Therefore, we decided that the Plan does not have to reimburse you for the dermatology service 
provided on November 2, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service November 
18, 2022. 
 
You asked the Plan to pay for procedure code 99140. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), shoulder x-ray (73030), and upper 
spine x-ray (72040) provided on November 23, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that the claim was initially submitted in January 
2022. You also say that this should be reprocessed and paid. The Plan denied your request. The Plan says the 
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 outpatient services was not filed until November 29, 2022. 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 office visit (99203), shoulder x-ray (73030), and upper spine 
x-ray (72040) provided on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on February 6, 2023. 
 
You asked the Plan to pay for the telehealth service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says telehealth services are not covered out-of-network. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the telehealth service have not been met. Therefore, we decided that the Plan does not have to pay 
for the telehealth visit provided on February 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided September 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you could not submit this on time due to the 
global pandemic. You request reconsideration of this claim for processing and payment. The Plan denied your 
request. The Plan says the claim was submitted past the timely filing limitation. 
 
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 November 23, 2022. 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 September 28, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for an additional unit of procedure code 93971 rendered on January 21, 
2023.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that while the documentation does not support that excess units were provided, there is no 
specific rationale as to why the additional needed to be performed. 
 
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 93971 is "Duplex scan of extremity veins including responses to compression and other maneuvers; 
unilateral or limited study." 
 
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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee had two different 
ultrasound unilateral exams - CPT 93971 x 2 - on January 21, 2023. Both of them were clinically indicated and 
correctly reported. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
an additional unit of procedure code 93971 rendered on January 21, 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 (87631) provided on January 19, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (87631) provided on 
January 19, 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 the services are medically necessary for the enrollee 
to get stronger before returning home. The Plan denied your request. The Plan says the services the enrollee 
requires can safely be received at a different setting, such as home with home health, in residential care, or 
home with close follow-up with their doctor.  
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service December 
13, 2022.  
 
You asked the Plan to pay for procedure code 99152. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99152 is bundled into payment for code 45385. 
 
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 99152 is a column II code to column I code 45385 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 99152 billed for date of service December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related 
supplies (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and related supplies. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
enrollee has not tried and failed a basic pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Because the base item E0652 cannot be approved in this case, the related supplies E0667 are also 
denied. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and related supplies (E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect testing (0012M) provided November 
29, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that the evidence supporting the use of Cxbladder 
Detect as medically necessary diagnostic service is well established and affirmed by Medicare. The Plan denied 
your request. The Plan says the Cxbladder 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the Cxbladder Detect testing (0012M) provided November 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires SNF services to overcome 
mobility issues and address functional deficits. 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 the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798 
billed for date of service November 30, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, and 87798. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says payment for code 87150, 87481, 87641, 87653, and 87798 is bundled into payment for codes 87500 and 87801.
 
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 87150 is a column II code to column I code 87500. 
We have confirmed that code 87481 is a column II code to column I code 87801. 
We have confirmed that code 87641 is a column II code to column I code 87801. 
We have confirmed that code 87653 is a column II code to column I code 87801. 
We have confirmed that code 87798 is a column II code to column I code 87801. 
 
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 codes 87150, 87481, 87641, 87653, and 87798 billed for date of service November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for each cochlear implant prosthetic provided 
on February 17, 2023. 
 
You asked the Plan to reduce the coinsurance for each cochlear implant prosthetic. You say that you were told 
both processors would cost a total of $1,900. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for each cochlear implant prosthetic. This item/service falls 
within the prosthetic devices and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. The amount you owe for each prosthetic device is $1,912.66 
($9,563.31 allowed amount x 20% = $1,912.66). The total amount you owe is $3,825.32 ($1,912.66 
coinsurance x 2 devices = $3,825.32). Therefore, we decided that the Plan does not have to reduce the 
coinsurance for each cochlear implant prosthetic provided on February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service November 
17, 2022.  
 
You asked the Plan to pay for procedure code 88360. You say that you disagree with the Plan's denial. 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 88360 is 3. The MAI value for this code is 3. You billed 6 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 88360 have not been met.  Therefore, we decided that the 
Plan does not have to pay for procedure code 88360 billed for date of service November 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 2, 2022, to May 
31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have correctly billed the 
services at issue. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 2, 2022, to May 31, 
2022.