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

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service July 19, 
2022, to July 26, 2022. 
 
You asked the Plan to pay for procedure code 99070. You say that all of the information that you have 
available has been provided. You also say that this should be paid. The Plan denied your request. The Plan says 
procedure code 99070 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 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service July 19, 2022, to July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 30, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 30, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
November 14, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 1, 2020. The Plan 
denied your request. The Plan says that the claim for these drugs was billed by the physician, not the opioid 
treatment program (OTP) facility. The rules say that only an entity enrolled with Medicare as an OTP can bill 
these codes.  
 
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 OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for 
medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on November 14, 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: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
September 19, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 1, 2020. The Plan 
denied your request. The Plan says that this code must be billed by the OTP facility on a facility claim. 
 
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 OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on September 19, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87500 billed for date of service March 28, 
2022.  
You asked the Plan to pay for procedure code 87500. You say that you disagree with the Plan's denial. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87500 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87500 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87500 billed for date of service March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
November 8, 2022. 
 
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 records do not support the services 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 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 enrollee underwent a right 
knee arthroplasty on this date of service. The review has determined that the records from the date of service 
did not support a comprehensive history, a comprehensive examination or medical decision making of high 
complexity. 
 
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) rendered on November 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided 
on November 29, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says this item was used outside the home and is non-
covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a pneumatic compression device (E0673, E0675) provided on November 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 12-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
your post-op appointment. The Plan denied your request. The Plan says the requested transportation exceeds 
your trip limit. 
 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 12 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 trips for routine transportation beyond the Plan's 
12-trip limit.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0426, A0425) provided on September 
26, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary and 
appropriate. The Plan denied your request. The Plan says these services are bundled into the facility payment 
where the enrollee maintained inpatient status on the date in question and are not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a facility, it may 
be necessary to transport the beneficiary to another hospital or site temporarily for specialized care while the 
beneficiary maintains inpatient status with the original provider. This movement of the patient is considered patient transportation and is covered in the payment made to the facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, the record shows that the enrollee maintained 
inpatient status at one facility from September 13, 2022, through September 28, 2022. This means that the 
services at issue are considered patient transportation and paid to the facility. Therefore, we decided that the 
Plan does not have to pay for ambulance services (A0426, A0425) provided on September 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuplazid. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nuplazid.   
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 9, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 
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 procedure code 76705 billed for date of service December 9, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0856) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the power wheelchair and accessories 
are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 a power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the provided 
records do not support that the enrollee is at a high risk for skin breakdown, has a history of pressure ulcer(s), 
or has had skin flap surgery. The records do not document the enrollee performs bladder self-catheterization or 
that the enrollee has increased muscle tone or spasticity to meet criteria for the power tilt and/or recline. Thus, 
the single power option wheelchair base does not meet Medicare criteria for coverage. As the PWC base is not 
medically necessary, the requested accessories are not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0856) and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test coded G0483 provided on September 27, 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 the services billed are 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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 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 submitted medical 
records do include a physician order; however, does not include laboratory requisition for 
definitive/confirmative drug test(s), 22 or more drug classes. Based on this information, we decided that 
Medicare rules for coverage of the drug test have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug test coded G0483 provided on September 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 
18, 2022. 
 You asked the Plan to pay for procedure code 76705. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 
93976. 
 
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 procedure code 76705 billed for date of service December 18, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve more than 36 hours of in-home support services for the 
2023 benefit year. 
 
You asked the Plan to pre-approve more than 36 hours of in-home support services. You say that you have a 
back injury, can hardly stand up to prepare meals, and need more than 36 hours of in-home support services. 
The Plan denied your request. The Plan says you can utilize up to 36 hours of in-home support services in 2023 
free of charge, but after the 36 hours, the benefit will be exhausted for free hours. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
 
 
 Though Medicare does not cover custodial care services, your Plan offers a supplemental benefit for in-home 
support services. Based on this information, we decided that Medicare rules for coverage of more than 36 hours 
of in-home support services have not been met. Specifically, your request exceeds the allowed 36 hours of in-
home support. The record shows that as of March 27, 2023, you still had 16 hours of in-home care remaining. 
Once the remaining 16 hours are used, totaling 36 hours, your benefit will be exhausted, but you can pay the 
out-of-pocket rate of $20 per hour if you wish to continue with the in-home care. Therefore, we decided that 
the Plan does not have to pre-approve more than 36 hours of in-home support services for the 2023 benefit 
year.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on September 9, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the items are not a covered benefit in this place 
of service. 
 
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 and appliance was used in an ambulatory surgical center. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliance 
provided on September 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service November 
14, 2022. 
 You asked the Plan to pay for procedure code 71045. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 
32557. 
 
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 71045 
is a column II code to column I code 32557. 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 71045 billed for date of service November 14, 
2022.