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

 
We decided that the Plan does not have to pay for the drug testing (G0481) provided from November 15, 2021, 
through November 22, 2021. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
  
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 G0481 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; 8-14 
drug class(es), including metabolite(s) if performed.  
We find that CPT code G0481 is not supported in the medical record. Review of the documentation does not 
support 8-14 drug classes, only 5 drug classes were tested. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing (G0481) provided from November 15, 2021, through November 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service August 10, 
2022. 
 
You asked the Plan to pay for procedure code 70480. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70480 is bundled into payment for code 70450. 
 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 70480 
is a column II code to column I code 70450. 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 70480 billed for date of service August 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that the physical therapy sessions are helping 
with your arthritis in your back and your physician recommends you continue. The Plan denied your request. 
The Plan says an additional 10 physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you do not require the unique skills of a professional therapist to 
safely and effectively provide treatment. The services can be safely and effectively performed only by a 
therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, 
and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design or 
deliver a program to maintain your current condition to prevent or slow further deterioration. You can 
transition to an independent home exercise program and does not require the ongoing skills of a professional 
therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 10 additional physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on August 23, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you are disputing the share cost. 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 $180 
copayment for outpatient hospital services.  
 
You have been asked to pay $97.29 which is less than the $180 copayment for CT scan. This item/service falls 
within the outpatient hospital services 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. Therefore, we decided that the Plan does not have to waive the copayment for 
CT scan provided on August 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on August 5, 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 September 15, 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 chest x-ray rendered on August 5, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on August 
8, 2022, to August 9, 2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you are disputing the share 
cost. 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 $90 
copayment for emergency care.  
 
You have been asked to pay $90 copayment for emergency room visit. This item/service falls within the 
emergency care 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. Therefore, we decided that the Plan does not have to waive the copayment for emergency room visit 
provided on August 8, 2022, to August 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 30, 2022, to 
February 9, 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 January 30, 2022. The NOA was not received by the Plan until December 
31, 2021. 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 January 30, 2022, to February 9, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on July 16, 
2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you are disputing the share 
cost. 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 $90 
copayment for emergency care.  
 
You have been asked to pay $90 copayment for emergency room visit. This item/service falls within the 
emergency care 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. Therefore, we decided that the Plan does not have to waive the copayment for emergency room visit 
provided on July 16, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from June 22, 2022, through July 11, 
2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says that there is no NOA claims submitted by the provider. 
 
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 home health services have been met. The rules say that the 30-
day period of care is the unit of payment for the home health prospective payment system (HH PPS). The 
period of care payment is specific to one individual homebound beneficiary. It pays all Medicare covered home 
care that is reasonable and necessary for the patient's care, including routine and nonroutine supplies used by 
that beneficiary during the period of care. It is the only Medicare form of payment for such services. Home 
health agencies (HHAs) shall no longer submit Requests for Anticipated Payment (RAPS -Type of Bill 0322) 
for any HH period of care with a From date on or after January 1, 2022. Instead, for each admission to home 
health, the HHA notifies Medicare systems via submission of a Notice of Admission (NOA). For all 
beneficiaries receiving HH services in 2021 whose services will continue in 2022, the HHA shall submit an 
NOA with a one-time, artificial 'admission' date corresponding to the "From" date of the first period of 
continuing care in 2022. Only one NOA is required for any series of HH periods of care beginning with 
admission to home care and ending with discharge. After a discharge has been reported to Medicare, a new 
NOA is required before the HHA submits any additional claims. Therefore, we decided that the Plan has to pay 
for the home health services provided from June 22, 2022, through July 11, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure (97110-GP) provided on August 1, 
2022. You asked the Plan to pay for procedure code 97110-GP. You say that this facility is a Comprehensive 
Outpatient Rehabilitation Facility (CORF) performing outpatient physical therapy services. Therefore, this 
code was billed correctly. The Plan denied your request. The Plan says this claim line was submitted 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that revenue code 42x (physical 
therapy) lines may only contain modifier GP. 
 
We find that the reported 97110-GP is not supported in the medical record. Specifically, this code was billed 
with revenue code 410 (respiratory services). Physical therapy services must be reported with a 42x revenue 
code, and respiratory therapy services shall not be represented by therapy codes which require GN, GO and GP 
modifiers. This service was reported inconsistently. Based on this information, we decided that Medicare rules 
for coverage of procedure code 97110-GP have not been met. Therefore, we decided that the Plan does not 
have to pay for therapeutic procedure (97110-GP) provided on August 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81291, 81401, 81335, 
81227) provided on July 20, 2022. 
 
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. The rules say that if one 
laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory 
shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, 
multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT code 
accurately describes the procedure performed, the laboratory may report CPT code 81479 (Unlisted molecular pathology procedure) with one unit of service or may report multiple individual CPT codes describing the 
component test results when medically reasonable and necessary. Procedures reported together must be both 
medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician who is 
treating the beneficiary and using the results in the management of the beneficiary's specific medical problem." 
Therefore, a single unit of 81479 represents one multigene test. Billing each gene individually would be 
incorrect coding. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT 
code(s): 81291, 81401, 81335, 81227) provided on July 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service March 27, 
2022. 
 
You asked the Plan to pay for procedure code 99233. You say that this service was medically necessary. 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 99233 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 99233 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99233 billed for date of service March 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87801) provided on May 5, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The test panel is a single 
test with multiple components and is characterized by a single unit of service (UOS = 1). A panel cannot be 
undundled and billed as individual components regardless of the fact that the test reports multiple individual 
pathogens and/or targets. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(87801) provided on May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01922 billed for date of service April 18, 
2022. 
 
You asked the Plan to pay for procedure code 01922. You say that your records indicate that CPT 01922 is not 
inclusive to any other CPT on date of service April 18, 2022. CTP 01922 is eligible for separate 
reimbursement. The Plan denied your request. The Plan says procedure code 01922 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 01922 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 01922 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 01922 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 01922 billed for date of service April 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided July 19, 2022 to July 29, 
2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim cannot be paid 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 these services are not supported in the medical record. Specifically, the number of units billed do 
not reflect the number of days of service (10). Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services provided July 19, 2022 to July 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lipid panel (80061) hemoglobin, glycosylated (A1c) (83036) 
thyroid stimulating hormone (TSH) (84443) and blood count, hemoglobin (85018) provided June 9, 2022. 
 You asked the Plan to pay for the laboratory services. You say that according to the Medicare guidelines these 
CPT's all meet medical necessity. The Plan denied your request. The Plan says non-contracted providers are 
required to furnish necessary information to the health plan when requested. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
additional records were required to determine how the enrollee came to the servicing provider, whether the 
services were medically necessary or whether the services were performed as billed. The records show that the 
Plan made multiple attempts to obtain the additional records from the provider without success. Therefore, we 
decided that the Plan does not have to pay for lipid panel (80061) hemoglobin, glycosylated (A1c) (83036) 
thyroid stimulating hormone (TSH) (84443) and blood count, hemoglobin (85018) provided June 9, 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 June 20, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these 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 June 20, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 15, 2022, to 
July 14, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be paid. 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 June 15, 2022, to July 
14, 2022.