Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 15, 2023, billed with 
procedure codes 96365-59 and 96366-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 96365-59 and 96366-59 is intravenous infusion, for 
therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, and intravenous infusion, 
for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in 
addition to code for primary procedure). 
 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the medical records support that 
procedure codes of the infusion 96365 and 96366 were performed, however coding these with modifier 59 is 
not appropriate and incorrect. Modifier 25 should be appended to 99214 and that is the only modifier needed. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 15, 2023, billed with procedure codes 
96365-59 and 96366-59.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of Pacing Electrode, placement of an 
electrode into the large heart vein with insertion into a pacemaker or implantable defibrillator pulse generator 
to help with the heart's function (33225). 
 
You asked the Plan to pre-approve the insertion of Pacing Electrode. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the records must note a slowing of the electrical signals 
in the bottom chambers of the enrollee's heart. 
 
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 the insertion of Pacing Electrode. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee has right bundle branch clock with QRS duration under 135ms, not left bundle branch block. As such, guidelines would not support implant of a CRT-D. In summary, 
there is insufficient documentation to support the medical necessity for implantation of a CRT-D in this 
enrollee's management. 
 
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 insertion of Pacing Electrode have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the insertion of Pacing Electrode, placement of an electrode into the 
large heart vein with insertion into a pacemaker or implantable defibrillator pulse generator to help with the 
heart's function (33225).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37228, 37232, & 76937 provided on 
January 12, 2023. 
 
You asked the Plan to pay for procedure codes 37228, 37232, & 76937. You say that this service was 
medically necessary. The Plan denied your request. The Plan says documentation does not support the billed 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 procedure codes 37228, 37232, & 76937. Our reviewer says 
that the billed codes are not supported. Our reviewer found insufficient medical documentation was provided to 
show that the procedures billed were performed on the date of service.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 37228, 37232, & 76937 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 37228, 37232, & 76937 provided on January 12, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left heart catheterization (93458). 
 
You asked the Plan to pre-approve a left heart catheterization. You say that you disagree with the denial and 
would like to request reconsideration. The Plan denied your request. The Plan says you do not meet criteria for 
approval of the requested procedure. 
 
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 a left heart catheterization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at issue is the medical appropriateness and necessity for performance of 
cardiac catheterization. You have had no chest pains. No non-invasive workup has been performed, such as a 
stress test. Documentation does not reveal the rationale for this invasive imaging study. Guidelines do not 
support a need for cardiac catheterization in this setting. As a result, at this time cardiac catheterization would 
not be considered medically appropriate and necessary in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a left heart catheterization (93458).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote physiologic monitoring provided on February 28, 
2023. 
 
You asked the Plan to pay for the remote physiologic monitoring. You say that the provider has no option to 
determine which patients they want to perform services on. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the remote physiologic 
monitoring provided on February 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that Retacrit is medically necessary. The Plan denied your 
request. The Plan says coverage rules are not met. 
 
The Plan follows Medicare rules. Medicare rules say that Erythropoiesis Stimulating Agents are covered when 
the patient has one of the following diagnosis: Anemia associated with cancer and related Neoplastic 
conditions, Anemia related to therapy with Zidovudine (AZT), Anemia associated with chemotherapeutic 
medications, Myelodysplastic Syndrome (MDS), Anemia of Chronic disease, Prophylactic pre-operative use 
for reduction of allogenic blood transfusions prior to elective hip and knee replacement surgery, Prophylactic 
pre-operative use for reduction of allogenic blood transfusions prior to elective noncardiac or nonvascular 
surgery, or Myelofibrosis.  
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 Retacrit. Our reviewer says that the 
requested medication is not medically necessary. Our physician reviewer found the enrollee does not have a 
covered diagnosis for this medication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a receiver (monitor), dedicated, for use with therapeutic 
continuous glucose monitor (CGM) system (K0554) provided on August 29, 2022. 
 
You asked the Plan to pay for a CGM receiver. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the requested CGM receiver is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code K0554 is not supported in the medical record. Specifically, if an enrollee never uses a 
receiver or insulin infusion pump to display CGM glucose data, the supply allowance is not covered by 
Medicare. Based on this information, we decided that Medicare rules for coverage of a CGM receiver have not 
been met. Therefore, we decided that the Plan does not have to pay for a receiver (monitor), dedicated, for use 
with therapeutic continuous glucose monitor (CGM) system (K0554) provided on August 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 is stable and suitable for 
transfer to an LTACH and cannot be adequately cared for in their current condition at a skilled nursing facility 
or any other lower level of care. You also say the enrollee is a high risk for readmission if sent to a lower level 
of care and cannot tolerate acute inpatient rehabilitation for 3 hours per day. The Plan denied your request. The 
Plan says admission to an LTACH 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 is receiving acute hospital care, and acute care services have not been denied. There are no required medical services identified that are available at the LTACH that are not 
available at the current health care setting being offered by the Plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on January 17, 2023, billed with 
procedure code R0070. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 R0070 is transportation of portable x-ray equipment and 
personnel to home or nursing home, per trip to facility or location, one patient seen. 
 
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 imaging services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that medical records do not fully support 
the use of procedure R0070. The documentation does not support where the patient was that the patient would 
need this mobile x-ray. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on January 17, 2023, billed with procedure code 
R0070.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology provided on September 20, 2021. 
 
You asked the Plan to pay for the diagnostic radiology. The Plan denied your request. The Plan says the claim 
was beyond 12 months of the date of service and denied for timely filing submission. 
 
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 diagnostic radiology was not filed until March 28, 2023. 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 diagnostic radiology provided on September 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim line 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. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on October 6, 2022. Comparison of the two claim lines shows these are exact duplicates. There is 
no evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 30, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 30, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479 and 81238.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided by a naturopath on March 28, 2023. 
 
You asked the Plan to pay for psychotherapy provided by a naturopath. You say that your prior policy covered 
services with this provider. The Plan denied your request. The Plan says this provider is not a recognized as a 
licensed physician according to the definition of a physician. Naturopath is not covered by Medicare under any 
condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for psychotherapy provided by a naturopath on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95999 billed for June 13, 2022. 
 
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 procedure code 95999 is 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 code 95999 is unlisted neurological or neuromuscular 
diagnostic procedure. 
 
We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that Train 
of Four testing was performed and there is a more appropriate code for the services. Based on this information, 
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 95999 billed for June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation trips for upcoming appointments. The Plan denied your request. The Plan says you have 
exhausted the maximum benefit of 24 one-way trips per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99232 provided on February 8, 2023. 
 
You asked the Plan to pay for procedure code 99232. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. In this case, the Plan denied payment for the evaluation and management service 
(99232) because it was billed on the same day as critical care services (99292 and 99291) without a 25 
modifier. However, Medicare guidelines say that the critical care codes should be billed with the 25 modifier 
when billed on the same day as an evaluation and management code. We find that the records support the 
billing of code 99232, and the Plan has provided no other rationale for their denial. Therefore, we decided that 
the Plan has to pay for procedure code 99232 provided on February 8, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 23, 2023, to 
February 21, 2023. 
 You asked the Plan to pay for the home health services. You say that this should be paid as you are certified by 
Medicare to provide home health services.  The Plan denied your request. The Plan says the NOA was not 
received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 23, 2023. The NOA was not received by the Plan until February 
24, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from January 23, 2023, to February 21, 2023.