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

 
We decided that the Plan does not have to pay for procedure codes 84436, 84479, and 84480, billed for date of 
service June 3, 2022. 
 
You asked the Plan to pay for procedure codes 84436, 84479, and 84480. The Plan denied your request. The 
Plan says payment for codes 84436, 84479, and 84480, is bundled. 
 
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 codes 
84436 and 84479 are column II codes to column I code 84439 with a modifier indicator of 0. We have also 
confirmed that code 84480 is a column II code to column I code 84481 with a modifier indicator of 0. The column II codes are therefore not payable. 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 codes 84436, 84479, and 
84480, billed for date of service June 3, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 
22869 and 22870). 
 
You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your 
request. The Plan says that medical studies have not proven that the service(s) or procedure(s) is helpful for 
treatment of your health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 surgery. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex superion interspinous device may be implanted at one or two adjacent lumbar 
levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. Based on 
the current medical literature, interspinous spacer interventions for symptomatic lumbar spinal stenosis have 
been shown to be safe and effective through five (5) years of follow-up. 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870).  
 
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: Favorable

 
We decided that the Plan has to pre-approve a prosthetic leg with an advanced foot feature. 
 
You asked the Plan to pre-approve a prosthetic leg with an advanced foot feature. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
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 prosthetic leg with an advanced foot 
feature. Our reviewer says that the services are medically necessary. Our physician reviewer found the 
documentation provided does support the use of the requested transtibial prosthesis with K3 components. The 
enrollee underwent a transtibial amputation on January 20, 2022 and requires a prosthesis for mobility and 
performing daily activities. The enrollee is noted to have full motor strength and range of motion in the lower 
extremities except for below the left knee joint. He can ambulate with a front wheel walker 100 feet and is 
attending physical therapy. There are no other medical conditions that would preclude him from achieving a K3 
level ambulator, which is supported by the enrollees health care provider and prosthetist. Therefore, the 
transtibial prosthesis with K3 components, specifically a K3 level foot flex walk system, is medically 
necessary. 
 
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 prosthetic leg with an advanced foot feature have been met. Therefore, we 
decided that the Plan has to pre-approve a prosthetic leg with an advanced foot feature.  
 
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 validity testing billed with code 83789 for date(s) of service 
January 4, 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 January 4, 2022.
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 May 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the lab services were 
medically necessary. 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 May 2, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 30, 2022, to 
May 29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 30, 2022, to May 
29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (88305) provided on September 13, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the ordering physician should have obtained 
authorization. The Plan denied your request. The Plan says this service is not covered when provided OON 
without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the lab services (88305) provided on September 
13, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on August 22, 2022. 
 
You asked the Plan to pay for the new patient office visit. The Plan denied your request. The Plan says the Plan 
only covers manual manipulation of the spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a new patient office visit provided on August 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage of an abscess involving the skin, 
subcutaneous and/or accessory structures (10061) provided March 4, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that please review the enclosed medical records 
and process this claim for payment as your doctor provided service to the enrollee in good faith. The Plan 
denied your request. The Plan says the claim was resubmitted past the timely filing limitation. 
 
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 surgical procedure was not filed until October 2, 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 incision and drainage of an abscess involving the skin, 
subcutaneous and/or accessory structures (10061) provided March 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 28, 2022, 
to March 30, 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 NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 28, 2022. The NOA was not received by the Plan until February 
28, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from February 28, 2022, to March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 provided on August 28, 2022. 
 
You asked the Plan to pay for procedure code 85060. 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 a Professional Component (PC)/Technical 
Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which 
separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the 
professional component of this procedure is only payable for inpatients. The services were billed with an outpatient place of service. Payment for this service cannot be made for hospital outpatients. Therefore, we 
decided that the Plan does not have to pay for procedure code 85060 provided on August 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-care/home management training services provided 
July 1, 2022, to August 1, 2022. 
 
You asked the Plan to pay for the self-care/home management training services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code 97535 is self-care/home management training (eg, 
activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and 
instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 
minutes. 
 We find that CPT code 97535 is not supported in the medical record. Specifically, the documentation shows 
that this code was billed with modifier G0. This is an incorrect modifier to be billed with this service. The 
services should be billed with a therapy modifier including GP, GO, and GN. Since this service was not billed 
with an appropriate modifier, the claim is not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of the self-care/home management training services have not been met. Therefore, 
we decided that the Plan does not have to pay for the self-care/home management training services provided 
July 1, 2022, to August 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheter drainage rendered on July 31, 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 payment is included in the global surgery package. 
 
The Plan must follow Medicare rules. The rules say that follow-up services are included in the global surgical 
package.  
 
We looked at the file and Medicare rules. Procedure code 49406 was related to and billed within 10 days of 
minor surgical procedure 10160 billed for July 26, 2022. Payment for code 49406 is included in the global 
surgical package. Therefore, we decided that the Plan does not have to pay for the catheter drainage rendered 
on July 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service December 4, 
2021 to December 31, 2021. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the denial. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service December 4, 2021 to December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on May 4, 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 procedure codes 99152 and 99153 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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. The definition of code 99153 is moderate sedation services provided by the same physician or 
other qualified health care professional performing the diagnostic or therapeutic service that the sedation 
supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's 
level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in 
addition to code for primary service). 
 We find that CPT codes 99152 and 99153 are not supported in the medical record. Specifically, there is no 
documentation of an independent trained observer monitoring the patient's level of consciousness and 
physiological status to support code 99152. Given that the primary procedure code is not supported, add-on 
code 99153 is also not supported. 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 moderate 
sedation services rendered on May 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 28315 billed for date of service April 26, 
2021. 
 
You asked the Plan to pay for procedure code 28315. You say that you disagree with the 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 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 28315 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 28315 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 28315 billed for date of service April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulation treatment provided on  
August 25, 2022. 
 
You asked the Plan to pay for chiropractic manipulation treatment. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for chiropractic manipulation treatment provided on 
August 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair, revision, and/or reconstruction procedures on the 
leg (tibia and fibula) and ankle joint (27698) open treatment of distal tibiofibular joint disruption with or 
without internal or external fixation) (27829) implantable pins and/or screws that are used to oppose soft tissue-
to-bone, tendon-to-bone, or bone- to-bone (C1713) provided on August 12, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the surgical services. You say that you request that the Plan review the enclosed 
medical records and overturn the denial and reprocess the claim for payment. 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. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the repair, revision, and/or reconstruction 
procedures on the leg (tibia and fibula) and ankle joint (27698) open treatment of distal tibiofibular joint 
disruption with or without internal or external fixation) (27829) implantable pins and/or screws that are used to 
oppose soft tissue-to-bone, tendon-to-bone, or bone- to-bone (C1713) provided on August 12, 2022, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for procedure code 77062. You say that you would like this claim to be reprocessed 
for payment. 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 June 21, 2022.