Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 01630-QZ. We decided 
that the Plan does not have to pay for the services described by procedure code(s) 99100.  
 
You asked the Plan to pay for practitioner services provided on July 3, 2023, billed with procedure codes 
99100 and 01630-QZ. You say that the claim is billed correctly and should be paid. The Plan says that code 
99100 is considered bundled and not separately payable.  
 
We decided that the Plan has to pay for the services described by procedure code(s) 01630-QZ.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 01630-QZ.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99100. 
 
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 looked at the file, and Medicare rules. We find that procedure code 99100 has a status indicator of B on the 
Physician Fee Schedule and is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the services described by procedure code(s) 99100 have not been met. Therefore, we 
decided that the Plan does not have to pay for the services described by procedure code(s) 99100. 
 
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 the PrismRA test (81479) provided on January 25, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on January 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent testing (87631) provided on May 15, 2023. 
 
You asked the Plan to pay for 87631. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says it would be more appropriate to bill code 87632. 
 
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 87631 is infectious agent detection by nucleic acid (DNA 
or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza 
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets. 
 
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 87631. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the lab ran 9 targets which does not fall within the range of code 
87631. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87631 have not been met. Therefore, we decided that the Plan does not have to 
pay for infectious agent testing (87631) provided on May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on February 9, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on February 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and related 
supplies (E667, E0673). 
 
You asked the Plan to pay for a pneumatic compression device and related supplies. You say that the items at 
issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment 
for a PCD have not been met. 
 
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. 
 
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, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) 
and related supplies (E667, E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet (UV) light therapy rendered on June 19, 2023. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that the use of infrared therapy devices and any related 
accessories is not reasonable and necessary. The rules say that items and services that are not medically 
necessary are not covered. 
 
The services/items at issue in this appeal are for infrared therapy. Therefore, we decided that the Plan does not 
have to pay for the ultraviolet (UV) light therapy rendered on June 19, 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 before the enrollee's surgery they were independent 
and could perform their daily activities with no help. After their surgery the enrollee needs moderate to max 
assist for ambulating as well as toileting. The Plan denied your request. The Plan says the inpatient 
rehabilitation facility (IRF) services you are requesting do not meet the requirements for approval.  
 
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. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. 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. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 18, 
2023. 
 You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 26, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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 May 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open implantation of cranial nerve (eg, vagus nerve) 
neurostimulator electrode array and pulse generator (Vivistim Paired Vagus Nerve Stimulation (VNS) 
System) (64568). 
 
You asked the Plan to pre-approve Vivistim Paired VNS system. You say that the enrollee has failed to 
recover using traditional rehabilitation during the 6-month period after a stroke. You say that the enrollee is left 
with permanent disability with no other treatment options available. You also say that this is medically 
necessary. The Plan denied your request. The Plan says this is considered experimental and therefore is not 
covered. 
 
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 Vivistim Paired VNS system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found vagus nerve stimulation for weakness after a stroke is an ongoing area of 
clinical research (ClinicalTrials.gov). Current clinical guidelines for adult stroke rehabilitation and recovery do 
not indicate that vagus nerve stimulation has been shown to result in long term health benefits in the Medicare 
population with hemiplegia following a stroke. Therefore, the reviewer found that the requested Vivistim 
Paired VNS system is 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 Vivistim Paired VNS system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve open implantation of cranial nerve (eg, vagus nerve) neurostimulator 
electrode array and pulse generator (Vivistim Paired Vagus Nerve Stimulation (VNS) System) (64568).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 6, 2022, to 
November 4, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was timely 
submitted. 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 October 6, 2022, to 
November 4, 2022.
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 is unable to move and continues to fall 
every time she tries to walk. You also say that she cannot move her right hand and is scheduled for surgery at 
the hospital and it would be easier for the enrollee to remain at the same hospital for inpatient rehabilitation. 
The Plan denied your request. The Plan says the record shows the enrollee does not meet Medicare guidelines 
for services in an inpatient rehabilitation facility.  
 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 medical record up until November 2, 2023, overall significantly complies with 
the various documentation requirements for IRF admission. Indeed, the enrollee's condition is in fact highly 
complex and fragile, and there is every reason to expect, assuming she tolerates her lower extremity arterial 
bypass surgery, that she will participate in and benefit from IRF-level services to include at minimum physical 
therapy, occupational therapy, physician oversight of post-op risks and polypharmacy, and case manager 
coordination of any additional services that might be needed to make a sustainable return. Based on that 
picture, it is very unlikely that her needs could be met in a skilled nursing facility. Based on the records up until 
November 2, 2023, since that time additional acute care has been deemed necessary. IRF placement at this 
juncture is contingent on the outcome of her surgery, which should necessitate a new IRF request with updated 
clinical records.Those records are not here available.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network skilled nursing facility 
(SNF) stay provided on June 01, 2023, to June 29, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network skilled nursing facility (SNF) stay. You say 
that you were informed the facility was in-network and authorized by the Plan. 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 30% 
coinsurance for skilled nursing facility care. 
 
You have been asked to pay 30% coinsurance for an out-of-network skilled nursing facility (SNF) stay. This item/service falls within the skilled nursing facility care 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 enrollee has been asked to pay $4,537.61, which is 30% 
of the allowed amount for an OON SNF stay ($15,125.37 allowed x 30% = $4,537.61). Therefore, we decided 
that the Plan does not have to waive the coinsurance for an out-of-network skilled nursing facility (SNF) stay 
provided on June 01, 2023, to June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Kit 2 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre Kit 2 sensor. You say that this is medically necessary. 
The Plan denied your request. The Plan says a CGM is covered under Medicare only if a member with diabetes 
is on insulin or has documentation of very low blood sugars that has occurred several times. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Libre Kit 2 sensor. Our 
reviewer says that the CGM is not medically necessary. Our physician reviewer found coverage criteria for 
CGM require insulin use or low blood glucose sugar. The enrollee is not having low blood glucose sugar we 
are told of and is not taking insulin as far as the notes state. Although the CGM may help the enrollee adjust 
diet and control blood glucose sugar, coverage criteria are not met.  
 
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 FreeStyle Libre Kit 2 sensor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a FreeStyle Libre Kit 2 sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11105 billed for date of service August 9, 
2023. 
 
You asked the Plan to pay for procedure code 11105. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this is an add-on code which was not billed 
with an appropriate primary procedure. 
 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 
procedure code 11105 is an add-on code and has not been billed with an appropriate primary procedure code. 
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 11105 billed for date of service August 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on May 18, 2023. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the billed service 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order or lab requisition for the specific testing provided in this case. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing provided on May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 12, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. 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 June 12, 2023.