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

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service November 
28, 2022. 
 You asked the Plan to pay for procedure code 81345. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service November 28, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gauze, conforming bandage, and tape provided on August 
26, 2022. 
 
You asked the Plan to pay for the gauze, conforming bandage, and tape. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the documentation is missing required information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. Review of the file has 
conflicting documentation regarding the ordering physician and the medical records provided. There was not a written order included with the records submitted. In addition, the Plan called the listed ordering physician's 
office and they confirmed they did not order any supplies for the enrollee. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the gauze, conforming bandage, and tape provided on August 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bupivacaine injection rendered on December 30, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately billable. 
 
The Plan must follow Medicare rules. The rules say that the use of local anesthesia performed to facilitate the 
infusion or injection or hydration (excluding chemotherapy) is not separately billable. 
 
We looked at the file and Medicare rules. The file shows that the bupivacaine injection billed with code J3490 
was billed on the same claim as injection procedure 27096. Code J3490 cannot be separately billed in this 
instance. Therefore, we decided that the Plan does not have to pay for the bupivacaine injection rendered on 
December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 7, 2022. 
 
You asked the Plan to pay for an office visit. You say that you believed this provider was in-network. The Plan 
denied your request. The Plan says this processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee. The rules also 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 paya $35 copayment for services obtained from a specialist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an office visit have not been met. Specifically, the record indicates that the Plan has paid the 
Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed amount as 
payment in full. In this case, the Plan is not responsible for paying the balance that remains after the Medicare 
allowed payment. You have been also asked to pay a $35 copayment for an office visit. This item/service falls 
within the services obtained from a specialist 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 pay for an office visit 
provided on September 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitamin D screening (82306) provided August 2, 2022. 
 You asked the Plan to pay for the laboratory service. You say that please review the attached medical records 
that supports the services rendered and overturn the denial that was in error and process for the denied amount 
of $29.60. The Plan denied your request. The Plan says 82306 is not a Medicare benefit for the diagnosis listed 
on the claim. 
 
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, the vitamin D screening, was requested solely for screening purposes. Per Local 
Coverage Article Billing and Coding: Vitamin D Assay Testing A57736, the current procedural terminology 
(CPT) 82306 was also not billed with one of the listed diagnosis codes that supports medical necessity. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the vitamin D screening (82306) provided August 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition supplies provided September 23, 
2022, to September 26, 2022. 
 
You asked the Plan to pay for the parenteral nutrition supplies. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says a proof of delivery was not provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the medical records do not include an enrollee receipt or proof of delivery for the supplies rendered 
for the billed dates of service. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the parenteral 
nutrition supplies provided September 23, 2022, to September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) provided on November 15, 2022. 
 
You asked the Plan to pay for the dental service. You say that the denied x-ray should be covered under your 
policy. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for the intraoral radiographic images (D0220 and D0230) on November 15, 202; therefore, 
your benefit for the requested item or service was exhausted on the date of service of November 15, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewings (D0274) provided on November 15, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drug coded J3490 provided on December 14, 
2022. 
 
You asked the Plan to pay for the unclassified drug. 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 J3490 is unclassified drugs. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this service was provided on 
the same date of service as surgery procedure 64490 (injection(s), diagnostic or therapeutic agent, paravertebral 
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level). This means code J3490 is included in the global surgical package for code 64490 and 
it not separately payable as billed. Based on this information, we decided that Medicare rules for coverage of 
the unclassified drug have not been met. Therefore, we decided that the Plan does not have to pay for the 
unclassified drug coded J3490 provided on December 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (rTMS). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that rTMS is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that there is no documentation in the 
submitted records that the enrollee received treatment with antidepressant medications in the current depressive 
episode. The criteria for coverage are not met and the rTMS is therefore not reasonable or medically necessary 
at this time. 
 
We looked at this physician's review, the file, and Medicare rules. 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 repetitive transcranial magnetic stimulation (rTMS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36415, 71046, 80053, 85025, 87641, 93005, 
and G0463 for date of service October 31, 2022. 
 
You asked the Plan to pay for procedure codes 36415, 71046, 80053, 85025, 87641, 93005, and G0463. 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 36415, 71046, 80053, 85025, 87641, 93005, and G0463 are not supported in the 
medical record. Specifically, code G0463 requires a procedure modifier. Code 71046 is a type S procedure and 
was provided on the same date of service as an evaluation and management service and was not billed with an 
appropriate modifier. Since the claim was not billed correctly, the claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of procedure codes 36415, 71046, 80053, 85025, 
87641, 93005, and G0463 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 36415, 71046, 80053, 85025, 87641, 93005, and G0463 for date of service October 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are limited by decreased endurance, balance and 
strength. You believe that you will benefit with inpatient rehab to maximize your functional independence and 
return home safely. The Plan denied your request. The Plan says the services you need can be provided safely 
in another setting such as a skilled nursing facility, home with home health services or home with outpatient 
therapy. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from the services due to the 
need for close physician management and monitoring. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare criteria for admission to an inpatient rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T2042 billed for date of service September 
22, 2022 to September 30, 2022. 
 
You asked the Plan to pay for procedure code T2042. You say that the billed code is valid. 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 T2042 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T2042 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code T2042 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T2042 billed for date of service September 22, 2022 to September 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99225 and 99226 billed for dates of service 
from July 7, 2022, to July 10, 2022. 
 
You asked the Plan to pay for procedure codes 99225 and 99226. You say that the services at issue have been 
billed correctly. 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, the CPT Code Manual definition of code 99225 is: Subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate 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 responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit;  
 
The definition of code 99226 is: Subsequent observation care, per day, for the evaluation and management of a 
patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed 
examination; Medical decision making of high 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 unstable or has developed a 
significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the 
patient's hospital floor or unit. 
 
We find that CPT codes 99225 and 99226 are not supported in the medical record. Specifically, the available 
records do not support that the enrollee was designated as being under observation care on the dates of service 
at issue in this case. Based on this information, we decided that Medicare rules for coverage of procedure codes 
99225 and 99226 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 99225 and 99226 billed for dates of service from July 7, 2022, to July 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided August 7, 2022, to August 
25, 2022. 
 You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
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 9, 2022. The NOA was not received by the Plan until March 27, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided August 7, 2022, to August 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on December 26, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that this claim should be paid. The Plan denied your 
request. The Plan says this service is not covered because it was provided OON without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on December 26, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
23, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 23, 2022.