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

 
We decided that the Plan does not have to pay for lab services provided on December 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services 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 December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue exam by pathologist (88305) provided on May 4, 
2022. 
 
You asked the Plan to pay for tissue exam by pathologist. You say that this service was medically necessary 
and was reported correctly. The Plan denied your request. The Plan says this claim was submitted with two 
diagnosis codes which cannot be billed together. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which should 
not be reported together.  
 We looked at the file and Medicare rules. This claim was submitted with both ICD-10 codes D12.2 and K63.5 
reported. However, D12 codes have an Excludes1 note which states that these codes should generally not be 
billed with benign carcinoid tumors of the large intestine, and rectum (D3A.02-) and polyp of colon not 
otherwise specified (K63.5). In addition, polyp of colon (K63.5) has an Excludes1 note which states that this 
code should not be reported with adenomatous polyp of colon (D12.-), inflammatory polyp of colon (K51.4-) 
and/or polyposis of colon (D12.6). Based on this information, we decided that Medicare rules for coverage of 
tissue exam by pathologist have not been met. Therefore, we decided that the Plan does not have to pay for 
tissue exam by pathologist (88305) provided on May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that there is poor circulation and a lot of discomfort, 
especially in the evening. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of skin substitute graft services and the 
axolotl graft provided on April 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the application of skin substitute graft services and the axolotl graft. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services rendered are not a 
covered benefit. 
 
 
 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 application of skin substitute graft services and 
the axolotl graft provided on April 28, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88361, 88312, 88305, and 
88104 provided on November 16, 2021. 
 
You asked the Plan to pay for the laboratory 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. 
 
We find that CPT codes 88361, 88312, 88305, and 88104 are not supported in the medical record. Specifically, 
these codes have a professional component/technical component of 1. These codes were billed with a place of 
service 22 (outpatient hospital). The professional interpretation was furnished in the same payment locality 
from where the technical component was furnished. This means these codes require modifier 26. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 88361, 88312, 
88305, and 88104 provided on November 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 1, 2022 
to June 17, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the services were medically necessary. 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 June 1, 2022 to June 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S9501 and S9502 billed for date of service 
November 12, 2021, to November 18, 2021. 
 
You asked the Plan to pay for procedure codes S9501 and S9502. You say that the S code is valid per the 
contract and the claim should be processed toward payment. The Plan denied your request. The Plan says the 
billed codes are 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 S9501 and S9502 have a Status Indicator of I on the Physician Fee Schedule. This 
means that procedure code S9501 and S9502 are not valid for Medicare purposes. Based on this information, 
we decided that Medicare rules for coverage of procedure codes S9501 and S9502 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes S9501 and S9502 billed for date 
of service November 12, 2021, to November 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on January 20, 2022. 
 
 
 You asked the Plan to pay for the psychotherapy services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the provider must attempt to consult the attending or primary care 
physician about the services furnished and document the consent or declination date to consultations, and the 
date of consultations in the enrollees medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick catheter and supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need the supplies due to advanced 
multiple sclerosis. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a PureWick catheter and 
supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from July 6, 2022, to 
July 9, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you would like to appeal because the 
medications given to you were required to be given through the hospital's pharmacy. The Plan denied your 
request. The Plan says these self-administered medications are not covered under Part B. 
 
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 pay for the self-administered drugs 
provided from July 6, 2022, to July 9, 2022.  
 Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care coded 99231 provided on June 
7, 2022. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 99231 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 problem 
focused interval history; A problem focused examination; Medical decision making that is straightforward or of 
low 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 stable, recovering or improving. Typically, 15 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
 We find that CPT code 99231 is not supported in the medical record. Specifically, this service is included in the 
related anesthesia claim billed by the same provider one day prior. Evaluation and management (E/M) services 
are included in the anesthesia for the anesthesiologist so they should not be billing the E/M service. The 
surgeon can bill the E/M service, but they are not to bill the anesthesia service. This means this service is not 
separately payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the 
subsequent hospital care coded 99231 provided on June 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cogenex amniotic membrane. 
 
You asked the Plan to pre-approve cogenex amniotic membrane. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that application of skin substitutes to ulcers or wounds is 
only covered for certain indications. 
 
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 cogenex amniotic membrane. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee demonstrates a nonpressure chronic ulceration to the left 
second digit with necrosis of muscle. The enrollee is noted to have diabetes with diabetic polyneuropathy. 
During a medical visit dated July 26, 2022, the enrollee is noted to have caught the left second toe while 
trimming toenails. The area became infected and the enrollee was placed on antibiotics. Physical examination 
reveals nonpalpable pedal pulses bilaterally with absent sensation to monofilament testing. The wound is noted 
to be full thickness ulceration with partial necrosis. The enrollees left second toe does demonstrate exposed 
bone with necrotic tissue and that the pedal pulses are diminished significantly which would most likely not 
allow for good healing. Therefore, the enrollee does not meet criteria for the requested cogenex amniotic 
membrane wound covering 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cogenex amniotic membrane have not been met. Therefore, we decided that the 
Plan does not have to pre-approve cogenex amniotic membrane.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care rendered on March 10, 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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 24, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the nursing facility care rendered on March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 26, 2021 billed with 
codes 81226, 81401, 81225, and 81227. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) 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 code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 26, 2021 billed with codes 81226, 81401, 81225, and 81227.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on June 29, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you cannot 
afford this copayment. 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). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $250 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. You have been asked to pay a $224.04 
copayment, rather than the full copayment of $250 for a computed tomography (CT) scan. Therefore, we 
decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan provided on 
June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy, 30 minutes, (90832) provided on February 
15, 2022. 
 
You asked the Plan to pay for the psychotherapy service. You say that this service should be covered. The Plan 
denied your request. The Plan says there is no documentation of contact with the attending or primary care 
physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy service have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for psychotherapy, 30 minutes, 
(90832) provided on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services provided on June 14, 2022. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says no medical records were provided 
to support that the services rendered were not for screening purposes.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that no medical records were provided from the referring provider. No documentation 
was provided to support that the services were provided not for screening purposes. Without this required 
documentation, this means that the mass spectrometry and tandem mass spectrometry services at issue in this 
appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening 
purposes. Therefore, we decided that the Plan does not have to pay for the mass spectrometry and tandem mass 
spectrometry services provided on June 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 3, 2021, billed with 
codes 81479, 81407, 81405, 81406, 81286, 81403, 81408 and 81404. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this claim was not billed in accordance with Medicare guidelines and 
was provided as a non-covered screening. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) 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 code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 3, 2021, billed with codes 81479, 81407, 81405, 81406, 81286, 81403, 81408 and 81404.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tattoo removal. 
 
You asked the Plan to pre-approve these services. You say that the tattoo is unhealthy for you. The Plan denied 
your request. The Plan says the services are cosmetic in nature and not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures are not covered. 
 
We looked the file and Medicare rules. The requested tattoo removal is a procedure to improve appearance and 
is cosmetic in nature. 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 pre-approve tattoo removal.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service June 27, 
2022. 
  You asked the Plan to pay for procedure code 71045. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment 
for code 71046. 
 
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 71046. 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 June 27, 2022.