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

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88364 and 88365) 
provided on September 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. 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. CPT code 88365-TC 
and 88364-TC, remain not supported. The place of service on the CMS-1500 form line 24B must reflect the 
location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory 
specimen was obtained in a laboratory POS 81; however, the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in an Outpatient hospital POS 22. Also, the laboratory results 
submitted indicate the specimen was collected on September 16, 2021, and received by the lab on September 
18, 2021. Of note, the patient resides in Arizona and the billing laboratory is located in New Jersey; therefore, 
the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information 
from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT 
code(s): 88364 and 88365) provided on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology (CPT code 88120) provided on March 23, 
2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says screening tests without a valid medical diagnosis related to the health of the patient are 
not a benefit. 
 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. 
 
The services are not authorized because code 88120 is not a Medicare benefit for the diagnosis listed on the 
claim (N39.3- Stress incontinence) and is done for screening purposes. The test at issue in this appeal, the 
services, was 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 cytopathology (CPT code 88120) 
provided on March 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion/specialty drug administration (CPT code 
99601) provided on August 3, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered 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. 
 
CPT code 99601 has a status code I, which is not valid for Medicare purposes. Medicare uses another code 
for reporting of and payment for these services. Based on this information, we decided that Medicare rules for 
coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the 
home infusion/specialty drug administration (CPT code 99601) provided on August 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography (75726-59-26) and angiography, each additional 
vessel (75774-59-26) provided on September 7, 2021. 
 
You asked the Plan to pay for the angiography services. You say that these services are supported as billed, and 
the enrollee had multiple services provided on this date. The Plan denied your request. The Plan says these 
services are not supported as billed. These services are included as part of the primary procedure (37244) and 
are not eligible for separate payment in this case. 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 
75726 and 75774 are both column II codes to column I code 37244; however, 75726 and 75774 were each 
billed with a modifier.  
 
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 angiography services. Our reviewer says that these 
services are not supported as billed with modifier 59. Our reviewer found these procedures are both inclusive to 
CPT 37244, as this procedure description includes all radiological supervision and interpretation. Therefore, 
CPT codes 75726 and 75774 would not be reported separately. 
 
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 angiography services have not been met. Therefore, we decided that the 
Plan does not have to pay for angiography (75726-59-26) and angiography, each additional vessel (75774-59-
26) provided on September 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 16, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 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. 
 
The test at issue in this appeal was 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 laboratory 
services rendered on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on November 4, 2021, and 
November 23, 2021. 
 
You asked the Plan to pay for the services provided. You say that you were under the impression that unlimited 
visits were covered. The Plan denied your request. The Plan says the maximum limit has been reached. 
 
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.  
 
We looked at the file and the rules. The records show that you received 18 chiropractic visits prior to the dates 
of service at issue in this appeal. Your plan contract shows that prior authorization is required if more than 18 
visits are needed. The file does not show that an authorization was obtained prior to the services being 
rendered. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on 
November 4, 2021, and November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on August 28, 2020. 
 
You asked the Plan to pay for the testing services. You say that the services have been deemed payable. The 
Plan denied your request. The Plan says the supporting documentation does not match the information on the 
claim. 
 
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 definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The records do not show that 22 
or more drug classes were tested due to clinical assessment, or a change in behavioral patterns.  Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on August 
28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided to the enrollee from 
September 2, 2021, to September 27, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not include the time spent providing this service; therefore, the billed 
Critical Care Evaluation and Management code cannot be verified. 
 
In this case, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there was no documentation 
showing the time spent providing the critical care services. This documentation is necessary as CPT 99291 is a 
time-based code. 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 critical care services provided to the 
enrollee from September 2, 2021, to September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aortography, abdominal plus bilateral iliofemoral lower 
extremity, catheter, by serialography, radiological supervision and interpretation (CPT code 75630-26-XU) 
provided on June 21, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 service. Our reviewer found documentation submitted 
was reviewed and does not meet criteria. CPT 75630 would be inclusive to CPT 37227, as angiography would 
be performed with a vascular procedure. Documentation does not support this procedure as an independent 
procedure from other services performed during same session. 
 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by 
serialography, radiological supervision and interpretation (CPT code 75630-26-XU) provided on June 21, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the stair lift purchased on July 21, 2021. 
 
You asked the Plan to reimburse for the stair lift. You say that you have ongoing medical issues which 
necessitates the use of a stair lift. You state you have been recently hospitalized for serious injuries and are 
unable to go up and down the stairs limiting your mobility. The Plan denied your request. The Plan says this 
item is considered not primarily medical in nature; and not a rental item and will deny non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to reimburse for the stair lift purchased on July 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
March 7, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no additional documentation supporting an additional study which was billed and 
remains denied. 
 
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 71045 is "Radiologic examination, chest; single view." 
 
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 records show a single 
one view chest x-ray was done on 3/7/21 and read by the doctor and signed at 12:15. No additional report of a 
second exam is in the records. 
 
 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 additional imaging services provided to the enrollee on March 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT), maxillofacial area (70486), 
provided on April 21, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CT. You say that the service is medically necessary. The Plan denied your 
request. The Plan says prior authorization must be obtained for non-emergent services provided by a out-of-
network provider. 
 
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 computed tomography (CT), maxillofacial area 
(70486), provided on April 21, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous epidural implantation of neurostimulator 
electrode array, (63650). 
 
You asked the Plan to pre-approve the procedure. You say that you are requesting review for medical necessity 
for the procedure and equipment. The facility will bill for the equipment to be used for this procedure. Please 
review for the doctor and facility. The Plan denied your request. The Plan says medical necessity cannot be 
established for the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a Dorsal root ganglion stimulator for the treatment of Complex regional pain syndrome is considered experimental/ investigational with only a few cases reported in the literature. He has other evidence 
based alternatives available to him. The request is therefore, deemed not medically reasonable or 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous epidural implantation of neurostimulator electrode array, (63650).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on October 1, 2021. 
 
You asked the Plan to pay for the services provided. You say that the codes are appropriately identified as 
separate services. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that CPT code 12011 was billed along with code 21310. We find that CPT code 12011 may be 
eligible for payment when billed with this code pair. The claim information does not show that the code at 
issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for the wound care services provided on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92012), provided on December 3, 2021. 
 
You asked the Plan to pay for the eye exam. You say that the services were provided in good faith. The Plan 
denied your request. The Plan says vision services must be obtained through the Plan's participating providers. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when obtained through in-network providers. 
 
We looked at the file and the Plan's rules. The service was obtained out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the 
Plan does not have to pay for the eye exam (92012), provided on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided to the enrollee from October 
4, 2021, to November 22, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denial of acupuncture was appropriate given the clinical scenario. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. The services must be performed by a qualified physician. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services were provided by a licensed 
acupuncturist, not a physician. Therefore, we decided that the Plan does not have to pay for acupuncture 
services provided to the enrollee from October 4, 2021, to November 22, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427) and ground mileage (A0425) provided on July 19, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee had revoked his hospice 
benefit on July 5, 2021. You also say that the ambulance provider in this case is the only ambulance provider in 
this area. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 5, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
advanced life support, emergency transport (A0427) and ground mileage (A0425) provided on July 19, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on December 28, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 93976 
is a column II code to column I code 76856. 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 ultrasound services provided to the enrollee on December 28, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision exam (92014), provided on December 3, 2021. 
 You asked the Plan to pay for the vision exam. You say that the services were provided in good faith. The Plan 
denied your request. The Plan says prior authorization must be obtained for non-emergent services provided by 
an out-of-network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you use a participating network provider. 
 
We looked at the file and the Plan's rules. the services were obtained out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the vision exam have not been met. Therefore, we 
decided that the Plan does not have to pay for the vision exam (92014), provided on December 3, 2021.