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

 
We decided that the Plan does not have to pay for the electrocardiogram (EKG) testing provided on February 7, 
2023, billed with 93010 and 93010-76. 
 You asked the Plan to pay for the EKG testing. You say that the claims are not duplicates. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. The rules 
also say that a repeat EKG should be billed with modifier -77 and is only paid under unusual and documented 
circumstances. 
 
We looked at the file and Medicare rules. The file includes evidence that code 93010 was reimbursed by the 
Plan on February 15, 2023. Comparison of the two claims shows these are exact duplicates for code 93010. 
There is no evidence presented to support that code 93010 was provided twice on the same date. Code 93010-
76 has not been submitted using an appropriate modifier. Based on this information, we decided that the 
Medicare rules for the EKG testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the electrocardiogram (EKG) testing provided on February 7, 2023, billed with 93010 and 93010-76.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight testing provided on September 28, 2022. 
 
You asked the Plan to pay for GeneSight testing. You say that this testing is covered by Medicare and this 
claim should be paid. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. In addition, the Plan claims that the order for this testing 
was not signed, and that this testing is not reasonable and necessary. 
 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 GeneSight testing 
have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight testing provided on 
September 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on January 24, 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 the criteria was not met, as the presenting problems were not high severity with a significant 
threat to life or physiologic function. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 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 evaluation included a history 
and physical exam, laboratory studies, an electrocardiogram (EKG) and a chest x-ray. All studies were normal 
and she was discharged home with a diagnosis of noncardiac chest pain. The review has determined that the 
records support that there was a medically appropriate history and examination but did not support that the 
medical decision making was highly complex. 
 
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 emergency department services (procedure code 99285) rendered on January 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (code 0012M) provided on June 8, 2022. 
 
You asked the Plan to pay for the testing. You say that this is a medically necessary diagnostic service. The 
Plan denied your request. The Plan says CxBladder testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing is non-covered. This non-
coverage rule applies regardless of appropriateness or medical necessity. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for 
CxBladder testing (code 0012M) provided on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210) provided on February 22, 2023. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images. You say that you were 
never informed you could only  have your teeth x-rayed every three years. The Plan denied your request. The 
Plan says your benefit for the intraoral - complete series of radiographic images 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 Plans 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 intraoral - complete series of radiographic images was exhausted on date of service 
August 25, 2021. Therefore, we decided that the Plan does not have to pay for an intraoral - complete series of 
radiographic images (D0210) provided on February 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee recently started a new medication and is 
a high fall risk. The Plan denied your request. The Plan says the IRF services requested 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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it was recommended that you enter an inpatient 
rehabilitation facility. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, your needs can be met at an alternate level of care.  
 
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 your 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 acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 87507 for date of service 
January 13, 2023. 
 
You asked the Plan to pay for code 87507. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this lab service does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the only diagnosis code that supports medical 
necessity for lab services billed with code 87507 is R19.7 (diarrhea, unspecified).  In addition to this required 
code, providers must bill an immunosuppression diagnosis. 
 
In this case, the only diagnosis you billed on this claim was A09.  The claim does not include the R19.7 
diagnosis code, which is required for coverage of 87507. Therefore, we decided that the Plan does not have to 
pay for lab services billed with code 87507 for date of service January 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36140 rendered on November 7, 2022. 
 
You asked the Plan to pay for the services. You say that the stenosis documented on the arteries highlighted in 
the notes shows that all procedures billed were completed in the procedure and the stenosis documentation 
shows the medical necessity for the procedures to be done. The Plan denied your request. The Plan says the 
claim was processed correctly, as the documentation does not support separate reporting of CPT 36140 with 
modifier -XU. 
 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 36140 is "Introduction of needle or intracatheter, upper or 
lower extremity artery." 
 
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 procedure report does 
describe catheterization. However, an intervention was performed, which includes catheterization procedures. 
Catheterization is included in CPT 37229. In this case, modifier XU unusual non-overlapping service cannot be 
verified. 
 
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 code 36140 rendered on November 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on August 25, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that these wound care supplies should be paid 
separately. The Plan denied your request. The Plan says the patient was in an inpatient status on the date of 
service, so no separate payment is made for these supplies.  
 
The Plan must follow Medicare rules. Medicare rules say that no separate payment is made for medical 
supplies provided while a patient is in an inpatient hospital stay. 
 
The records show that the patient was an inpatient in the hospital on the dates these supplies were provided.  As 
a result, no separate payment can be made for these supplies. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wound care supplies have not been met. Therefore, we decided that the Plan does not have to 
pay for wound care supplies provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010) provided on March 8, 2023, to 
March 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 Plans 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 17, 2018. 
Therefore, we decided that the Plan does not have to pay for an endosteal implant (D6010) provided on March 
8, 2023, to March 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are strong enough to complete the recommended 
therapy and everyone agrees you need therapy. The Plan denied your request. The Plan says the enrollee does 
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 you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a 
different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 30, 2022, 
to October 29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services should be covered as 
you disagree with the denial. 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 September 30, 2022, to 
October 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires extended acute care.  
The Plan denied your request. The Plan says an LTACH admission is not medically necessary.  
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye examination provided on March 20, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the eye examination. You say that the provider relies on the nursing facility to 
obtain authorization. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 did not pre-approve the 
eye examination. We found no exception that would require the Plan to pay for the eye examination. Therefore, 
we decided that the Plan does not have to pay for the eye examination provided on March 20, 2023, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on February 24, 2023. 
 
You asked the Plan to pay for the medication. You say that you have submitted the denial of payment to be 
reimbursed. 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 pay for self-administered drugs provided 
on February 24, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services rendered from February 22, 2021, 
to February 28, 2021. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the submitted clinical documentation does not support the coding of 
isolation for active infection. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that the MDS is supplied but no 
supporting documentation for the MDS indication of infection. The record from the appealing facility does not 
provide evidence of an infection requiring isolation. The plan has coded correctly. 
 
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 physical therapy services rendered from February 22, 2021, to February 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare 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 Dupixent.