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

 
We decided that the Plan has to pay for radiological services provided on March 16, 2022, billed with code 
77014. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that the charge is incidental to another service. 
 
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 denied this claim as being inclusive to another procedure. However, 
there is no evidence that it is inclusive to the other code billed on the claim, and no other evidence was 
presented to identify which service the code at issue is inclusive to. As such, the denial of payment is not 
substantiated. Therefore, we decided that the Plan has to pay for radiological services provided on March 16, 
2022, billed with code 77014.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on March 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
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 (G0483) provided on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on May 4, 2022. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the claim was billed with 
the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that for all services (with two (2) exceptions), the 
POS code to be used by the physician or other supplier will be assigned as the same setting in which the 
beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital 
inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported 
regardless of where the face-to-face service takes place.  
 
We looked at the file and Medicare rules. The outpatient visit (99212) in this case was billed with an inpatient 
POS code (21). An outpatient visit should be billed with an outpatient place of service. Based on this 
information, we decided that Medicare rules for coverage of the visit have not been met. Therefore, we decided 
that the Plan does not have to pay for the office visit (99212) provided on May 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service May 5, 2022. 
 
You asked the Plan to pay for procedure code 77062. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service May 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Spinal Simplicity/Minuteman device. 
 
You asked the Plan to pre-approve the device. You say that the physician identified key findings which support 
medical necessity. The Plan denied your request. The Plan says a review of the current medical literature 
indicates that this service is considered experimental and investigational. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the device is experimental. More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Spinal Simplicity/Minuteman device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve the services. You say that this denial is not cost effective, as it would 
require resumption of systemic therapy for a prolonged period of time. The Plan denied your request. The Plan 
says based on the additional information available, the request does not meet the Medicare or health plan 
coverage criteria. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in general, IMRT over 3D radiation therapy (3DRT) would be justifiable as it is plausible that IMRT 
would afford a clinically meaningful benefit. However, in this case, the intent seems to be palliative as the case 
records discuss consolidating treatment after partial response. The treatment (selectively treating 1-2 
oligometastases with IMRT) is not standard practice. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intensity-modulated radiation therapy (IMRT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87900 billed for December 9, 2021. 
 
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 87900 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 87900 is infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics. 
 
We find that CPT code 87900 is not supported in the medical record. Specifically, there is no documentation of 
quantitative infectious agent drug susceptibility. 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 87900 billed for December 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from July 19, 2022, to 
August 9, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB code. 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 the home health services rendered from 
July 19, 2022, to August 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) provided to 
the enrollee on April 21, 2021. 
 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not sufficiently 
support that there was a detailed exam, detailed interval history, and medical decision making of high 
complexity to justify use of CPT 99233. The presentation and workup revealed a low complexity and low 
severity case.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99233) provided to the enrollee on April 21, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Gel-One. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not trialed 
viscosupplemental treatments such as Orthovisc, and Synvisc or Synvisc One. The documentation does not 
outline contraindications or reasons these medications were not considered or that the plan's additional required 
drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of 
the documentation, Gel-One is not approved, as step criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services billed with codes 75716-59 and 75774-
59 on September 19, 2022. 
 
You asked the Plan to pay for the services. You say that the claim is billed correctly The Plan denied your 
request. The Plan says CPT 75716 and 75774 are not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that in 
terms of CPT 75716, the procedure report does not include documentation to support, no prior catheter-based 
angiographic study was available, and a full diagnostic study is performed, and the decision to intervene is 
based on the diagnostic study. Therefore, this procedure would be included in the intervention service. In terms 
of CPT 75774, this procedure would be included in the intervention procedure. The documentation does not 
support a separate and distinct procedure. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for radiological services billed with codes 75716-59 and 75774-59 on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dental services on September 6, 2022. 
 
You asked the Plan to waive the copayment for the dental services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 50% coinsurance for the dental services.  
 
The enrollee has been asked to pay a 50% coinsurance for the dental services. This item/service falls within the 
Major Dental Services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
dental services on September 6, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care (99223) billed for date of service October 17, 
2022. 
 
You asked the Plan to pay for inpatient hospital care. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. Specifically, the Plan's denial states that procedure code 99223 is an inpatient-
only code billed for outpatient services. However, the case record supports that the claim is for inpatient 
services as place of service (POS) is reported as 21, indicating an inpatient hospital. Additionally, the Plan 
states that code 99223 was billed on a prior claim. The documentation of the prior claim as provided by the 
Plan does not support that code 99223 was previously billed. It is the Plan's responsibility to substantiate its 
denial with evidence. In this case, the Plan's denial has not been substantiated, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for inpatient hospital care (99223) billed for date of service 
October 17, 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test provided on January 13, 2022. 
 
You asked the Plan to pay for the drug test. You say that you disagree with the Plan's 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 drug test 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 the drug test provided on January 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) provided to the 
enrollee on October 30, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not sufficiently 
support that there was decision making of high complexity for this hospital visit to justify CPT 99223. 
Additionally, the records do not have documentation of a comprehensive exam or history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) provided to the enrollee on October 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on June 16, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says the code used to report these services is not supported in 
the medical record, as the documentation shows that only 20 drug classes were tested in this case, rather than 
22 or more. 
 
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 drug test(s), definitive, 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records provided do not 
support that 22 or more drug classes were tested in this case. Based on this information, we decided that 
Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for definitive drug testing (G0483) provided on June 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43239 billed for date of service September 
14, 2022. 
 
You asked the Plan to pay for procedure code 43239. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 43239 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 43239 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 43239 billed for date of service September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided on September 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
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 (G0482) provided on September 12, 2022.