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

 
We decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service September 
15, 2021. 
 You asked the Plan to pay for procedure code(s) 88381. You say that this should not be required to have a 
professional component modifier since the testing is not related to the hospital stay. 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 the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88381. 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) 88381. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88381 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service September 15, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service November 
23, 2021. 
 
You asked the Plan to pay for procedure code A4550. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A4550 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 A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4550 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4550 billed for date of service November 23, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital services (82947, 27447, 97162) provided from 
October 28, 2022, to October 30, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that additional payment is due. The Plan 
denied your request. The Plan says that these services are being paid on the inpatient claim. 
 
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 file does not support that there is a claim for inpatient services 
that was paid. The file also does not support that the services in this case are on that claim and were paid. 
Therefore, we decided that the Plan has to pay for the outpatient hospital services (82947, 27447, 97162) 
provided from October 28, 2022, to October 30, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot be safely discharged home. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions, alveoplasty and anesthesia. 
 
You asked the Plan to pre-approve the dental services. You say that due to your medical condition you keep 
getting infections and request these services be covered under your medical benefit. The Plan denied your 
request. The Plan says these services are not covered by Medicare or the Plan. 
 
This service would not be covered under your medical benefit because they are not extractions to prepare the 
jaw for radiation treatments. Therefore, we decided that the Plan does not have to pre-approve extractions, 
alveoplasty and anesthesia.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from November 26, 2021, to 
December 20, 2021. 
 
You asked the Plan to pay for home health care. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the request for anticipated payment (RAP) was not submitted within 5 calendar 
days of the from date for this billed period of care. 
 
The Plan must follow Medicare rules. Medicare rules say that for periods of care beginning in the 2021 
calendar year, the RAP must be submitted within 5 calendar day after the start of care of from date for a 
period of care.  
 
We looked at the file and Medicare rules. The RAP for this claim was not submitted until March 1, 2022. 
Based on this information, we decided that Medicare rules for coverage of home health care have not been met. 
Therefore, we decided that the Plan does not have to pay for home health care provided from November 26, 
2021, to December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99358 billed for date of service November 4, 
2022. 
 You asked the Plan to pay for procedure code 99358. The Plan denied your request. The Plan says payment for 
code 99358 is bundled into payment for code 99310. 
 
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 99358 
is a column II code to column I code 99310. 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 99358 billed for date of service November 4, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy tablet 50mg. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
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 Ubrelvy tablet 50mg.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on January 13, 2023. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused. The Plan denied your request. The 
Plan says the D0140 limited oral evaluation - problem-focused service provided to the member is not covered 
by the Plan or Medicare. 
 
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. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation - problem 
focused are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for a limited oral evaluation - problem focused (D0140) provided on January 13, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for application of a modality to 1 or more areas; whirlpool 
rendered on November 10, 2022. 
 
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 this denied code is part of the primary procedure and and cannot be paid separately. 
 
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 97022 is "Application of a modality to 1 or more areas; 
whirlpool." 
 
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 not supported by the medical records. Our reviewer found that in this case, modifier -59 for a 
distinct procedural service is not supported. This procedure was performed in the same anatomical area, and 
therefore would be included in the more comprehensive procedure provided. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for application of a modality to 1 or more areas; whirlpool rendered on November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97016, J1955, J3411, J3415, J3420 rendered 
on September 8, 2022. 
 
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 the denied codes remain 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 the denied codes is: 
 
CPT 97016: 
 
Application of a modality to 1 or more areas; vasopneumatic devices  
Healthcare Common Procedure Coding System (HCPCS) J1955: 
 
Injection, levocarnitine, per 1 gm 
 
HCPCS J3411: 
 
Injection, thiamine hcl, 100 mg 
 
HCPCS J3415: 
 
Injection, pyridoxine hcl, 100 mg 
 
HCPCS J3420: 
 
Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg 
 
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 not supported by the medical records. Our reviewer found that in terms of CPT 97016, the 
procedure does not include documentation of a vasopneumatic device application. In terms of the injection 
codes, the procedure reports that Nutria-pharmaceutical blend/mix was performed. Therefore, the injections 
would not be reported separately. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 97016, J1955, J3411, J3415, J3420 rendered on September 8, 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 enrollees 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 foot wound and had a below the knee amputation. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on June 
9, 2022. 
 
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 the documents do not support this level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 not supported by the medical records. Our reviewer found that the history and physical 
examination were not comprehensive. As such, the billing of CPT 99223 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on June 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided July 2, 2022, to 
July 16, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient stay was medically 
necessary. The Plan denied your request. The Plan says the medical criteria for an inpatient stay has not been 
met. 
 
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 enrollee's condition stabilized and improved, and she was discharged home when 
considered medically stable on 07/16/2022. 
 
 
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 July 2, 2022, to July 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation taxi-intra city. 
 
You asked the Plan to pre-approve the services. You say that the enrollee needs transportation to receive the 
enrollee's radiation treatments five days a week for seven weeks. The Plan denied your request. The Plan says 
the enrollee has used 24 trips and has additional trips scheduled, which fulfills the full benefit allowance. 
 
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.  
 
Review of the file shows that the enrollee has used 24 trips and has additional trips scheduled. The 33rd trip 
and beyond is not a covered benefit. The enrollee's 2023 EOC states that The Plan contract says that enrollees 
must pay a $0 copayment for 32 one-way trips per calendar year. Therefore, we decided that the Plan does not 
have to pre-approve additional non-emergency transportation taxi-intra city.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitamin D, 25 hydroxy, includes fraction(s), if performed 
(82306) provided December 16, 2022. 
 
You asked the Plan to pay for the vitamin D testing. You say that please review. Diagnosis code N18.2 meets 
medical necessity per the Plan guidelines. The Plan denied your request. The Plan says medical necessity 
cannot be established. 
 
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 vitamin D testing have been met. 
medical records were requested to support how the enrollee came to the servicing provider or whether the 
services are medically necessary. The records show that the Plan made multiple attempts to obtain the records 
from the provider without success. Therefore, we decided that the Plan does not have to pay for the vitamin D, 
25 hydroxy, includes fraction(s), if performed (82306) provided December 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the criteria for 
medically appropriate long term acute care admission. The Plan denied your request. The Plan says the 
enrollee's hospital course is not complete and may stay in the hospital to finish the hospital treatments. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (SelectMDX) 
(81479) provided June 9, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that please process for review. The Plan denied 
your request. The Plan says the genetic testing was not medically necessary. 
 
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 laboratory service have been met. 
medical records were needed from the provider. The records show that multiple attempts were made to obtain 
the records from the provider without success. Therefore, we decided that the Plan does not have to pay for 
unlisted molecular pathology procedure (SelectMDX) (81479) provided June 9, 2021.