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

 
We decided that the Plan does not have to pay for procedure code 01992 billed for date of service December 5, 
2022.  
 
You asked the Plan to pay for procedure code 01992. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 01992 is bundled into 
payment for code 64420-RT. 
 
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 01992 is a column II code to column I code 64420-RT with a modifier indicator of 0. The column I code was billed on 
the same date of service by a provider with the same specialty in the same billing group. The column II code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 01992 billed for date of service December 5, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 14, 2022, to 
October 28, 2022. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted on January 4, 
2023, and you believe this is timely. 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 October 14, 2022. The NOA was not received by the Plan until January 5, 
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 home health services provided 
from October 14, 2022, to October 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service January 6, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records have the details to support 
the service billed. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
 We find that 13 units of CPT code 87798 is not supported in the medical record. The records do not identify the 
specific organisms associated with this code. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87798 billed for date of service January 6, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport, and 
ground mileage provided on March 16, 2022. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the services were 
medically necessary and therefore payable. The Plan denied your request. The Plan says that our policy covers 
non-emergency ambulance transportation when it is the only way to safely and adequately transport a member 
or if other means of transporting a member are unsafe due to a medical condition. This claim does not meet 
these requirements. 
 
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 the ambulance service and ground mileage. 
Our reviewer says that the ambulance services were medically necessary. Our physician reviewer found the 
enrollee was diagnosed with exposed hardware after a back surgery with possible active infection as well as 
dementia with behavioral disturbance, non-ambulatory status and inability to transfer. Records document the 
patient refused vital signs and required the assistance of multiple caregivers to be transferred onto the 
ambulance stretcher. The presence of the wound on the back contraindicated any other mode of transportation. 
Based on the medical records provided there is support that the ambulance transport was medically reasonable 
and 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 the ambulance service and ground mileage have been met. Therefore, we 
decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport, and ground 
mileage provided on March 16, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior tibial neurostimulation (PTNS) (64566). 
 
You asked the Plan to pre-approve the PTNS. You say that the enrollee has tried Gemtesa with minimal results. 
You say that the enrollee would like to avoid further medications given their medical history. You also say that 
for these reasons PTNS is medically necessary for the enrollee. The Plan denied your request. The Plan says 
there is no documented failure or contraindication to medication therapy, insufficient improvement after non-
procedural therapy, overactive bladder syndrome, or symptoms not due to underlying neurological condition. 
 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 PTNS. Our reviewer says that the 
requested PTNS is not considered medically reasonable and necessary in this case. Our physician reviewer 
found this treatment is a technique of electrical neuromodulation used primarily for the treatment of voiding 
dysfunction in patients who have failed behavioral therapies and/or pharmacologic therapies. The records do 
not show that the enrollee has tried and failed behavioral therapy such as bladder training or pelvic floor 
muscle training. Also, PTNS is not indicated for the treatment of urinary incontinence without sensory 
awareness and stress urinary incontinence. Therefore, the reviewer found that the requested PTNS is not 
medially 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 the PTNS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve posterior tibial neurostimulation (PTNS) (64566).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Purewick female urinary system purchased on February 
10, 2023. 
 
You asked the Plan to pay for the Purewick female urinary system. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item was purchased through a provider that is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the Purewick female urinary system 
purchased on February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 23, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the semi electric hospital bed (E0260), delivery (A9901), and 
tax (S9999) purchased on April 13, 2023. 
 
You asked the Plan to pay for the semi electric hospital bed, delivery, and tax. You say that the items should be 
covered. The Plan denied your request. The Plan says this was purchased through a provider that is not enrolled 
in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the semi electric hospital bed (E0260), 
delivery (A9901), and tax (S9999) purchased on April 13, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Breast Cancer Index testing (81518) billed for date of service April 20, 
2023. 
 
You asked the Plan to pay for Breast Cancer Index testing. You say that this test was medically necessary and 
was reported appropriately. The Plan denied your request. The Plan says that this claim was submitted with an 
incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. However, there are exceptions to this rule. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Breast Cancer Index testing have been met. Specifically, the specimen in this case was a tissue 
sample which would have been collected during a medically necessary and appropriate hospital stay, and the 
test itself was performed after discharge. It is also likely the sample was stored for some time. Based on the 
documentation provided, one of the exceptions has been met, which means that the appropriate date to report in 
this case would be the date the test was performed. In this case, the correct date is April 20, 2023. Therefore, 
we decided that the Plan has to pay for Breast Cancer Index testing (81518) billed for date of service April 20, 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0429, A0425) provided on March 19, 
2023. 
 
You asked the Plan to pay for ambulance services. You say that this was not a duplicate claim as the enrollee 
was transported twice on this date. 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. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 5, 2023. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for ambulance services have not been met. Therefore, 
we decided that the Plan does not have to pay for ambulance services (A0429, A0425) provided on March 19, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service March 6, 
2023. 
 
You asked the Plan to pay for procedure code 99140. You say that the service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99140 is considered bundled and not separately 
payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service March 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a heavy-duty walker purchased on January 9, 2023. 
 
You asked the Plan to pay for heavy-duty walker. You say that you do not have to bend over when using this 
model of walker. The Plan denied your request. The Plan says this provider does not participate in Medicare 
and is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered items or services, 
a provider or supplier must be enrolled in Medicare.  
 
We looked at the file and Medicare rules. This supplier is not enrolled in Medicare and is not payable. Based 
on this information, we decided that Medicare rules for coverage of heavy-duty walker have not been met. 
Therefore, we decided that the Plan does not have to pay for a heavy-duty walker purchased on January 9, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service February 18, 
2023, to March 19, 2023. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. 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 February 18, 2023. The NOA was not received by the Plan until April 12, 
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 for 
date of service February 18, 2023, to March 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 27, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service April 4, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the testing was based on medical necessity. The 
Plan denied your request. The Plan says the lab results do not meet the criteria for 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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The records do not show that 22 
or more drug classes were tested. There is a more accurate code that describes the services provided. 
 Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code G0483 billed for date of 
service April 4, 2023.
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 admission is medically necessary for the 
enrollee.  The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care 
and does not require transfer to a Long-Term Acute Care Hospital. 
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks. 
 
You asked the Plan to pre-approve the injections. You say that due to the failure of conservative treatments to 
address pain and restore function this procedure is the best option. The Plan denied your request. The Plan says 
the request is not medically necessary. 
 
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 injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee pain. 
 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture therapy (97810, 97811, 97026, 97139, 
97814). 
 
You asked the Plan to pre-approve acupuncture therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says the requested provider is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve acupuncture therapy (97810, 97811, 
97026, 97139, 97814).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 23, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the diagnosis codes were not received from 
the referring provider until late. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until April 6, 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 the laboratory services provided on March 23, 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 criteria for admission. 
The Plan denied your request. The Plan says the enrollee is receiving the care needed in the current hospital 
and there is no need to transfer to the LTACH at this time. 
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 long term acute care hospital (LTACH) services.