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

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service April 20, 
2023. 
 You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code 80307 and 
G0480. 
 
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 83789 
is a column II code to column I code 80307 and G0480. 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 83789 billed for date of service 
April 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 18, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator charge that you reference has not yet was not officially implemented until October 1, 2023. This date 
is well prior to your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance (D4910).

You asked the Plan to pre-approve the dental services. You say that you do not understand why you are being charged for this. 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 Plan's 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 July 29, 2022, and October 24, 2022. Therefore, we decided that the Plan does not have to pre-approve periodontal maintenance (D4910).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenetics panel provided on 
November 17, 2022, and billed with codes 81408, 814101, 81335, 81227, 81225, 81230, 81231, 81355, 81232, 
81226, 81240, and 81241. 
 
You asked the Plan to pay for the comprehensive pharmacogenetics panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing should be billed with a single 
panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the comprehensive pharmacogenetics panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive 
pharmacogenetics panel provided on November 17, 2022, and billed with codes 81408, 814101, 81335, 81227, 
81225, 81230, 81231, 81355, 81232, 81226, 81240, and 81241.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on April 21, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that the patient was not enrolled in hospice on 
the date of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 1, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on April 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377) 
and push handles (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the accessories are necessary for the 
approved wheelchair. The Plan denied your request. The Plan says the upgraded electronics cannot be covered 
as there is not a medical need to control the requested power options through the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has left sided weakness as residual from a stroke. He has an intact right 
side. Per SSA 1862 (a)1 (a), the enrollee has sufficient strength and function in his upper extremities to manage 
standard power drives. Push handles do not serve a medical purpose on a power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313), an expandable controller (E2377) and push handles 
(K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97750 billed for date of service February 22, 
2023. 
 
You asked the Plan to pay for procedure code 97750. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says this code is not supported, as the documents do not 
include a clear plan of care or the time spent providing this service. 
 
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 97750 is physical performance test or measurement (e.g., 
musculoskeletal, functional capacity), with written report, each 15 minutes. 
 
We find that CPT code 97750 is not supported in the medical record. Specifically, the time spent providing 
these services is not documented in the medical record. Without this information, a time-based code such as 97750 cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure 
code 97750 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
97750 billed for date of service 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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the required services for the enrollee can be provided in 
an alternate setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. The enrollee does not require treatment by multiple therapies. 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 the 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on September 27, 2022 to 
October 26, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 the home health services are not supported in the medical record. Specifically, F03.918 is not a 
valid primary diagnosis code for the home health services billed. A medical diagnosis must be the primary 
diagnosis code. Based on this information, we decided that Medicare rules for coverage of the home health 
services have not been met. Therefore, we decided that the Plan does not have to pay for home health services 
provided on September 27, 2022 to October 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on June 20, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. There is a more appropriate code to billed for the panel provided in 
this case. Based on this information, we decided that Medicare rules for coverage of the panel have not been 
met. Therefore, we decided that the Plan does not have to pay for the lab panel provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular diagnostic testing (0326U) provided on June 2, 
2023. 
 
You asked the Plan to pay for molecular diagnostic testing. You say that this testing is covered and was 
medically necessary. The Plan denied your request. The Plan says this testing was not billed with the required 
DEX Z-Code. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic tests must be billed with the 
appropriate DEX Z-Code identifier adjacent to the procedure code in the comment/narrative field.  
 We looked at the file and Medicare rules. This test was not billed with the required DEX Z-Code. Based on this 
information, we decided that Medicare rules for coverage of molecular diagnostic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for molecular diagnostic testing (0326U) provided on 
June 2, 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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet all the requirements 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 the clinical documentation does not specify any complex functional impairments; 
thus, the complexity of the enrollee's documented nursing, medical and rehabilitation needs would not be 
expected to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The clinical documentation shows that the enrollee requires ongoing physical therapy and occupational 
therapy, but does not justify the medical necessity of an intensive rehabilitation regimen in an IRF 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 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 pre-approve geriatric home care services to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve geriatric home care services by the requested out-of-network provider. You 
say that your husband has Alzheimers dementia with behavior issues and it is not safe nor realistic for your 
husband to go into a clinic for care as he is a homebound patient at this time. You say that this provider 
provides geriatric care for adult family homes and long-term facilities and has the training and expertise to 
support ongoing care for dementia patients like your husband. The Plan denied your request. The Plan says 
geriatric care can be safely and appropriately provided by the Plan's in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve geriatric 
home care services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76937 and 93451 billed for date of service 
May 2, 2023. 
 
You asked the Plan to pay for procedure codes 76937 and 93451. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says these codes are 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 this service was provided to the enrollee while an outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 76937 and 93451. This means there is 
both a professional and technical component for the CPT codes. In this case, an appropriate modifier to indicate 
the professional component has not been billed with CPT codes 76937 and 93451. Based on this information, 
we decided that Medicare rules for coverage of procedure codes 76937 and 93451 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 76937 and 93451 billed for date 
of service May 2, 2023.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the supplies for a home monitoring device provided 
on April 23, 2022, June 2, 2022, July 7, 2022, August 25, 2022, and November 10, 2022. We decided that the 
Plan does not have to waive the coinsurance for the supplies for a home monitoring device provided on January 
12, 2023, and March 23, 2023.  
 
You asked the Plan to waive the coinsurance for the supplies for a home monitoring device provided on 
January 12, 2023, and March 23, 2023. You say that you have not been billed for this service in the past. The 
Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the supplies for a home monitoring device 
provided on April 23, 2022, June 2, 2022, July 7, 2022, August 25, 2022, and November 10, 2022.  
 
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. The Plan has not provided an Evidence of Coverage to show that the cost share 
was applied correctly. Therefore, we decided that the Plan has to waive the coinsurance for the supplies for a 
home monitoring device provided on April 23, 2022, June 2, 2022, July 7, 2022, August 25, 2022, and 
November 10, 2022.  
 
We also decided that the Plan does not have to waive the coinsurance for the supplies for a home 
monitoring device provided on January 12, 2023, and March 23, 2023. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay $31.80, which is 20% coinsurance of the allowed amount for each medical supply 
provided on April 23, 2022, to March 23, 2023 ($159 allowed amount x 20% = $31.80). You have been asked 
to pay a total of $63.60 ($31.80 coinsurance x 2 supplies = $63.60). These items/services fall within the durable 
medical equipment and related supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for the supplies for a home monitoring device provided on January 12, 2023, and March 23, 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: 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 due to the complexity of this enrollee 
and prior hospitalization, they will continue to require acute care for a period of time before they will be safe 
enough to transition to a lower level of care. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval. 
 
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 improving but still requires acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services and these have not 
been denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. 
 
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 lab services provided on March 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 9, 2022.