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

 
We decided that the Plan does not have to pay for procedure code 11720 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 11720. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 11720 is bundled into payment for code 11719. 
 
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 11720 
is a column II code to column I code 11719. 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 11720 billed for date of service July 27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on April 4, 2022. 
 
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 that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on April 4, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service August 18, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service August 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for spinal surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says studies have not proven that this procedure is helpful. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental in spinal surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for spinal surgery.
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 June 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 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 June 1, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (85014, 85018, 85049, 80048, 85025, 36415, 
84443, 85027) provided on September 9, 2020. 
 
You asked the Plan to pay for the lab services. You say that this claim should be covered. 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 lab services was not filed until June 1, 2022. 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 lab services (85014, 85018, 85049, 80048, 85025, 36415, 84443, 85027) 
provided on September 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 17, 2020, 
to September 21, 2020 at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the submitted records do not support the billing of diagnosis code A41.9. Our physician 
reviewer found the enrollee presented to the emergency department with weakness. She was found to have 
pneumonia and a urinary tract infection. She was started on intravenous antibiotics and admitted. There is no 
clinical or laboratory evidence of sepsis. The records do not support the billing of diagnosis code A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 17, 2020, to September 21, 2020 at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81227, 81226, 81231 
and 81225) provided on May 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. If one laboratory 
procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report 
only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte 
assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT code accurately 
describes the procedure performed, the laboratory may report CPT code 81479 (Unlisted molecular pathology procedure) with one unit of service or may report multiple individual CPT codes describing the component test 
results when medically reasonable and necessary. Procedures reported together must be both medically 
reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician who is treating the 
beneficiary and using the results in the management of the beneficiary's specific medical problem." Therefore, 
a single unit of 81479 represents one multigene test. Billing each gene individually would be incorrect coding. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81227, 
81226, 81231 and 81225) provided on May 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service June 17, 
2022. 
 
You asked the Plan to pay for procedure code 99232. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 99233. 
 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 99232 
is a column II code to column I code 99233. 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 99232 billed for date of service June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with an auricular stimulator (64555, L8679). 
 
You asked the Plan to pre-approve an auricular stimulator. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulation will be 
denied as non-covered. Based on this information, we decided that Medicare rules for coverage of an auricular 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with 
an auricular stimulator (64555, L8679).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99217) provided on August 17, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the code 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. 
 
In this case, the CPT Code Manual definition of code 99217 is observation discharge services. 
 
We find that CPT code 99217 is not supported in the medical record. Specifically, when a patient is admitted 
for observation care and then is discharged on a different calendar date, the physician shall report Initial 
Observation Care, from CPT code range 99218 - 99220, and observation care discharge, CPT code 99217. 
Records only show a subsequent care code billed prior to the discharge code. Based on this information, we 
decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided 
that the Plan does not have to pay for physician services (99217) provided on August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. 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 June 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service is medically necessary and should be 
paid. 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 June 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (83789) provided on June 20, 2022. 
 You asked the Plan to pay for procedure code 83789. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 83789 is bundled into payment for code 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 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. Furthermore, the 
documents received do not support that the procedure or service was distinct or independent from other 
services performed; therefore, the use of the 59 modifier is not supported. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (83789) provided on June 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested services Our physician reviewer found that the record indicates that the enrollee has had more than 
three scans following initial treatment. The record indicates that the enrollee had a scan showing no disease in 
April and September 2022 after being treated for a presumed recurrence seen in January. The record provided 
is insufficient to establish the medical necessity of the requested service 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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve positron emission tomography (PET) scan.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to hold you harmless for ambulance services provided on July 1, 2022. 
 
You asked the Plan to hold you harmless for ambulance services. You say that this should be covered. The Plan 
denied your request. The Plan says that the services were billed with the GY modifier and cannot be covered. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules. The Plan contract also states that if 911 is 
contacted and an ambulance is sent to transport you, you may be held liable for payment if you decline the 
ambulance ride or you take the ambulance and it is determined your symptoms are not emergent. 
 
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 hold you harmless for ambulance services. Our 
reviewer says that the records show that your presenting symptoms met prudent layperson criteria for 
emergency care. Our physician reviewer found the records show that you had symptoms significant 
sluggishness and concern for carbon monoxide exposure after recent work on a furnace in the home.  
 
We looked at this physician's review, the file, and Medicare rules. Although the services at issue were billed 
with a GY modifier to indicate the services do not meet criteria for coverage, the records do not indicate that 
the ambulance services were not emergent. The Plan contract states that you may only be held liable if you 
decline the ambulance ride or you take the ambulance and it is determined your symptoms are not emergent. 
Based on this information, we decided that Medicare rules for coverage of ambulance services have been met. 
Therefore, we decided that the Plan has to hold you harmless for ambulance services provided on July 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig, any type, each (A9282) purchased June 30, 2022, 
from an out of network provider. 
 
You asked the Plan to pay for the wig. You say that you lost your hair the second week of chemo. You were 
told that your insurance would provide a wig. You purchased the wig and was also told the insurance would cover the cost. The Plan denied your request. The Plan says enrollees must receive their medical services from 
an in-network provider with the exception being urgent or emergent services. This item is not covered. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Also, the servicing provider in this case is not a network provider with the Plan. 
The Plan did not pre-approve the item/service at issue. Therefore, we decided that the Plan does not have to pay 
for the wig, any type, each (A9282) purchased June 30, 2022, from an out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for subsequent nursing facility care provided on April 29, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the physician provided the care in 
good faith. The Plan denied your request. The Plan says that according to our records the precertification entity 
was not contacted for precertification. 
 
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 has not provided us with the Medicare rule or the Plans 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for subsequent nursing facility 
care provided on April 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99205) provided on July 8, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed 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 99205 is an office visit. 
 
We find that CPT code 99205 is not supported in the medical record. Specifically, the documentation shows 
this service was provided in the Emergency Department. There is a more appropriate code for this service. 
Based on this information, we decided that Medicare rules for coverage of the physician services have not been 
met. Therefore, we decided that the Plan does not have to pay for physician services (99205) provided on July 
8, 2022.