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

 
We decided that the Plan does not have to pay for the blood smear interpretation provided on October 22, 2021. 
 
You asked the Plan to pay for the services provided. You say that the procedure was rendered in the 
appropriate place of service. The Plan denied your request. The Plan says an inappropriate place of service was 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by 
physician with written report. We looked at the file and the rules. We find that CPT code 85060 was billed with 
a place of service 23, an emergency room. No payment is recognized for code 85060 furnished to hospital 
outpatients or non-hospital patients. Based on this information, we decided that Medicare rules for coverage of 
the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the blood 
smear interpretation provided on October 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on October 14, 
2021. 
 
You asked the Plan to pay for the abdominal ultrasound. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says an appropriate modifier was not 
billed with this code as required by Medicare coding regulations. 
 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 76705 
is a column II code to column I code 93976. 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 the abdominal ultrasound (76705) provided on October 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Psychosocial rehabilitation services (H2017) provided 
from August 23, 2021, to October 1, 2021. 
 
You asked the Plan to pay for code H2017. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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 looked at the file and Medicare rules. In this case, CPT code H2017 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have 
to pay for the Psychosocial rehabilitation services (H2017) provided from August 23, 2021, to October 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Hyaluronan injection provided on June 
18, 2021. 
 
You asked the Plan to waive the coinsurance for a Hyaluronan injection. You say that you receive injections in 
your knees every three months. You also say that you received an injection on June 18, 2021. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 Part B drugs.  
 
You have been asked to pay $165.81, which is 20% of the allowed amount for a Hyaluronan injection ($829.06 
allowed amount x 20% coinsurance = $165.81). A Hyaluronan injection falls within the Medicare Part B 
Prescription Drugs 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 a Hyaluronan 
injection provided on June 18, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that it is necessary to receive 
transportation to your medical appointments. The Plan denied your request. The Plan says you have exhausted 
the benefit for routine transportation. 
 
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 50 one-way 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the requested treatment is a medical necessity for you. 
The Plan denied your request. The Plan says rules for coverage have not been met because the use of the 
requested drug as prescribed is off-label and not medically accepted. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that a 
request was made for coverage of Botox to be administered every 8 weeks. At the present time the drug is only 
indicated for administration every 12 weeks in both the FDA-approved labeling and the Medicare-accepted 
compendia. There is not literature available to otherwise independently permit conclusions on the safety and 
efficacy of Botox being provided more often than every 12 weeks. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Botox (J0585).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test provided on July 5, 2021. 
 
You asked the Plan to pay for the laboratory test. You say that the provider is an independent lab that performs 
services at the independent laboratory in California. You say that the place of service and date of service were 
billed accurately, and the service should be paid. The Plan denied your request. The Plan says the place of 
service on the claim form must reflect the location of the patient when the specimen was obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that the Place of Service 
(POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We find that CPT code 0242U is not supported in the medical record. Specifically, this claim was billed with 
the laboratory place of service code while the records suggest that the members face-to-face service was 
rendered in a hospital setting. Based on this information, we decided that Medicare rules for coverage of the 
laboratory test have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
test provided on July 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided May 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the 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 find that CPT code 81479 is not supported in the medical record. Specifically, the place of service on the 
claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81479) provided May 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the records provided 
support the need for inpatient psychiatric services. The Plan denied your request. The Plan says an inpatient 
psychiatric hospital is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee 
was admitted to the acute inpatient psychiatric hospitalization on February 25, 2022. It was expected the 
enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or 
homicidal ideation noted and no visual hallucinations. The enrollee realizes that she has auditory 
hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or 
others and was compliant with her treatment. It did not appear that the services were reasonably expected to 
improve the enrollees condition or for the purpose of diagnosis beyond the date in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673) provided May 28, 
2021. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the device was medically 
necessary. The Plan denied your request. The Plan says this device was used in an inpatient setting and is not 
eligible for separate payment. 
 
  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device was used in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0673) provided May 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen and 
pelvis. 
 
You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the claim has not been billed in accordance 
with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that providers should use 
modifier KX with procedure codes that are gender specific in the particular cases of transgender, ambiguous 
genitalia, and hermaphrodite beneficiaries.  
 
In this case, the CPT Code Manual definition of code 74177 is computed tomography, abdomen and pelvis; 
with contrast material(s). We looked at the file and Medicare rules. In this case, the claim has been billed with a diagnosis code of 
N83.291 defined as other ovarian cyst, right side. This diagnosis code is not normally billed for a member 
whose gender is male. In these circumstances, Medicare coding regulations requires a modifier of KX be 
reported for circumstances with gender specific codes for transgender, ambiguous genitalia, and hermaphrodite 
beneficiaries. This modifier was not billed with the claim. Based on this information, we decided that Medicare 
rules for coverage of the CT scan services have not been met. Therefore, we decided that the Plan does not 
have to pay for the computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided October 15, 2021. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this 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 CPT code 99213 is not supported in the medical record. Specifically, follow-up visits during the 
postoperative period of the surgery are not separately payable. This visit was within the 90 day global surgery 
period from the pacemaker placement performed on September 15, 2021. No modifier was billed to show this 
service was unrelated. Based on this information, we decided that Medicare rules for coverage of the office 
visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99213) 
provided October 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot be properly cared for at home. Without 
the coverage your health and well-being will decline dramatically. The Plan denied your request. The Plan says 
you do not meet Medicare criteria for coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance for spine or back muscle injection 
(77003) provided on April 23, 2021. 
 
You asked the Plan to pay for fluoroscopic guidance for spine or back muscle injection. You say that you 
would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan 
says this claim has not been billed with an acceptable primary procedure 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, we have confirmed that code 
fluoroscopic guidance for spine or back muscle injection is an add-on code and has not been billed with an 
appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for fluoroscopic guidance for spine or back muscle 
injection (77003) provided on April 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic services (97110) provided on July 26, 2021. 
 
You asked the Plan to pay for the therapeutic services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-
physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and 
not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. 
Therefore, we decided that the Plan does not have to pay for the therapeutic services (97110) provided on July 
26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80053, 80061) provided October 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says this testing was for screening purposes and is not covered. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (80053, 
80061) provided October 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 3, 2022. 
 
You asked the Plan to pre-approve SNF care after March 3, 2022.. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care after March 3, 2022. Our 
reviewer says that you do not meet the Medicare criteria for continued SNF care. Our physician reviewer found 
you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or 
skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care after March 3, 2022. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on October 5, 
2021. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you were not aware of the 
copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 a $150 
copayment for outpatient surgery at an outpatient hospital. 
 
 You have been asked to pay a $150 copayment for cataract surgery. Cataract surgery falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 copayment for cataract surgery provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 1, 2021.