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

 
We decided that the Plan does not have to pay for the definitive drug testing provided on June 10, 2021. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the POS code reported is not appropriate. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that 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 drug testing 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 the definitive drug testing provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on January 3, 2022 to 
January 6, 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 code 99291 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. 
 
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 is no documentation of 
critical care time spent on the enrollee. 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 critical 
care services rendered on January 3, 2022 to January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99284) provided on 
December 25, 2021. 
 
You asked the Plan to pay for an emergency department visit. You say that you have provided records to 
support the service billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 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 99284 
is a column II code to column I code 99285. 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 an emergency department visit (99284) provided on December 
25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services provided on February 8, 2022. 
 
You asked the Plan to pay for the services provided. You say that the medical records provide evidence of 
medical necessity. The Plan denied your request. The Plan says the place of service is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by 
physician with written report. We looked at the file and the rules. We find that CPT code 85060 was provided in an outpatient hospital 
setting. No payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the blood smear services provided on February 8, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for arthroscopy, shoulder, surgical; with lysis and resection of adhesions, 
with or without manipulation (CPT code 29825-59) provided on May 13, 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 that the services are not supported by the records. 
 
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 found the May 13, 2021, operative 
report noted a Smith and Nephew coagulator wand was utilized to perform a capsular release in a 360-degree 
fashion, with the anterior release performed at the anterior rotator interval. This was repeated at the posterior 
portal. The records do support that the CPT code 29825-59- arthroscopy, shoulder, surgical; lysis and resection 
of adhesions with or without manipulation was performed. (This was over and above a 3 structure extensive 
debridement reflected in and or inclusive to 29823-RT, which would not be/is not applicable.) 
 
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 been met. Therefore, we decided that the Plan has to pay for 
arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation (CPT code 
29825-59) provided on May 13, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT, head or brain; without contrast material (CPT code 
70450) provided on February 13, 2022. 
 
You asked the Plan to pay for the CT scan. 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. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 CT, head or brain; without contrast material (CPT code 70450) 
provided on February 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex device. 
 
You asked the Plan to pre-approve a Coflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 a Coflex device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Coflex device at L3/4 and L4/5, in 
this case, is 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 a Coflex device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Coflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services provided from September 2, 2021, 
through September 28, 2021, by a provider not certified with Medicare. 
 
You asked the Plan to pay for the office services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the services were received by a provider who is 
not under contract with the health plan and has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care.  
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
services provided from September 2, 2021, through September 28, 2021, by a provider not certified with 
Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit for the evaluation and 
management of a patient (CPT code 99285) and rhythm ECG, 1-3 leads; interpretation and report only (CPT 
code 93042) provided on September 1, 2021. 
 
You asked the Plan to pay for the services. You say that the services were rendered in an emergent 
circumstance. The Plan denied your request. The Plan says the services are not covered by Medicare or the 
health plan. 
 
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 services have not been met. Medicare excludes from coverage 
items and services furnished to beneficiaries in State or local government custody under a penal statute, unless, 
it is determined that the State or local government enforces a legal requirement that all prisoners/patients repay 
the cost of all healthcare items and services rendered while in such custody and also pursues collection efforts 
against such individuals in the same way, and with the same vigor, as it pursues other debts. CMS presumes that a State or local government that has custody of a Medicare beneficiary under a penal statute has a financial 
obligation to pay for the cost of healthcare items and services. Therefore, Medicares policy is to deny payment 
for items and services furnished to beneficiaries in State or local government custody. Therefore, we decided 
that the Plan does not have to pay for emergency department visit for the evaluation and management of a 
patient (CPT code 99285) and rhythm ECG, 1-3 leads; interpretation and report only (CPT code 93042) 
provided on September 1, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custodial care provided from August 20, 2021, to 
December 1, 2021. 
 
You asked the Plan to pay for the custodial care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the custodial care 
provided from August 20, 2021, to December 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for submucous resection inferior turbinate, partial or complete, 
any method (CPT code 30140-50) provided on April 28, 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 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 30140-50 is submucous resection inferior turbinate, 
partial or complete, any method. 
 
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 found the clinical documentation 
does not support submucous resection of the inferior turbinate, partial or complete, by any method. 
 
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 submucous resection inferior turbinate, partial or complete, any method (CPT code 30140-50) 
provided on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s): 81404, 81405, 
81406 81407, 81408, and 81479) provided on July 15, 2021. 
 
You asked the Plan to pay for the molecular pathology testing. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or 
more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one 
CPT code must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for the 
molecular pathology testing (CPT code(s): 81404, 81405, 81406 81407, 81408, and 81479) provided on July 
15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunohistochemistry or immunocytochemistry services 
coded 88342 and 88341 provided on August 17, 2021. 
 
You asked the Plan to pay for the immunohistochemistry or immunocytochemistry services. You say that you 
would like the plan to reconsider their 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, we have confirmed that codes 
88342 and 88341 are column II codes to column I code 88360. 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 the immunohistochemistry or 
immunocytochemistry services coded 88342 and 88341 provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest and CT 
scan of the abdomen and pelvis to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CT scan of the chest and CT scan of the abdomen and pelvis to be 
provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan 
says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not 
been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a computed tomography (CT) scan of the chest and CT scan of the abdomen and pelvis to be provided by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the right shoulder brace provided on January 25, 2022. 
 
You asked the Plan to pay for the shoulder brace. You say that the records support the need for this brace. The 
Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed 
the need for the billed supply code. 
 
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 right shoulder brace provided on 
January 25, 2022. have been met. The progress note submitted for review was for the same date as the order for 
the shoulder brace was signed. However, the progress note does not support the presence of the diagnosis code 
listed on the order or the claim. There is no documentation in the record of shoulder pain or of any intent to 
order braces. Therefore, we decided that the Plan does not have to pay for the right shoulder brace provided on 
January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve whole body imaging to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve whole body imaging to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
whole body imaging to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arthrocentesis (20611). 
 
You asked the Plan to pre-approve Arthrocentesis (20611). You say that the requested Arthrocentesis (20611) 
is medically necessary. The Plan denied your request. The Plan says the requested Arthrocentesis (20611) is 
not medically necessary. 
 
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 Arthrocentesis (20611). Our reviewer 
says that the requested Arthrocentesis (20611) is not medically necessary. Our physician reviewer found there 
is no documentation of objective findings on physical examination to support a diagnosis of right shoulder 
pain, imaging findings to corroborate a diagnosis of right shoulder pain and rule out other possible causes of 
this enrollee's pain, or documentation of conservative treatment including physical therapy in addition to the 
enrollee's oral pain medications. The review has determined that the requested procedure is not medically 
reasonable or necessary for the enrollee in this case. 
 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Arthrocentesis (20611) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Arthrocentesis (20611).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided on 
February 10, 2022. 
 
You asked the Plan to pay for the abdominal ultrasound. 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. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided on 
February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Factor V Leiden (CPT code 81241) provided on May 
26, 2021. 
 
You asked the Plan to pre-approve the laboratory service. You say that you did know this provider was out-of-
network. The Plan denied your request. The Plan says the records do not support that the Factor V Leiden test 
was medically necessary and there are no notations as to why the test was ordered. 
 
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 laboratory service. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found medical records indicate that CPT 82141 F5 Gene analysis was ordered, but does not 
notate why. The records do not support that the Factor V Leiden test was medically necessary. There are no 
notations as to why the test was ordered. The review has determined that the obtained service was 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Factor V Leiden (CPT code 81241) provided on May 26, 2021.