Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device 
(E0720) billed for date of service April 27, 2022. 
 
You asked the Plan to pay for a TENS device. You say that the requested item was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met because a "to" date 
of service was not provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and specify whether equipment is rented or 
purchased. 
 In this case, you have billed a TENS device as a rental item. The claim does not specify the timespan over 
which the equipment at issue was rented. The claim requires a range of dates. Based on this information, we 
decided that Medicare rules for coverage of a TENS device have not been met. Therefore, we decided that the 
Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device (E0720) billed for 
date of service April 27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided to the enrollee on February 22, 2022. 
 
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 that the date of service was reported incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service for clinical laboratory tests 
must be the date that the specimen was collected. However, there is an exception for Advanced Diagnostic 
Laboratory Tests (ADLT). 
 
When Advanced Diagnostic Lab Tests are done as an outpatient, and are considered medically necessary, the 
date of service used should be the date the test was actually performed, instead of the date the specimen was 
collected. There is no evidence in the case file presented by the plan that the services were done to an inpatient 
enrollee. The plan has not addressed the medical necessity of the services. 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 laboratory services provided to the enrollee on February 22, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9270 billed for date of service May 9, 
2022. 
 
You asked the Plan to pay for procedure code A9270. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is not covered by Medicare. 
 
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 A9270 has a Status Indicator of N on the Physician Fee Schedule. This means that 
procedure code A9270 is not covered by Medicare. Based on this information, we decided that Medicare rules 
for coverage of procedure code A9270 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A9270 billed for date of service May 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 8, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was not billed with a similar 
code. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 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. Code 70496 was billed by a physician of the same specialty at the 
same facility. 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 70450 billed for date of service March 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnography, sleep monitoring of patient 6 years 
or older in a sleep lab. 
 
You asked the Plan to pre-approve polysomnography. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that follow-up polysomnography or sleep studies are not 
routinely indicated for patients treated with CPAP whose symptoms continue to be resolved with CPAP 
treatment. 
 
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 polysomnography. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a repeat polysomnography is not 
medically necessary.  This patient has severe obstructive sleep apnea (OSA), as demonstrated on an attended polysomnography on 
June 26, 2020. A positive airway pressure (PAP) titration on October 16, 2020 showed that bilevel positive 
airway pressure (BiPAP) 18/14 was effective in treating the sleep disordered breathing. There is no need to 
repeat these studies. It is reasonable to approve a 3-month repeat trial of BiPAP at the previous settings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve polysomnography, sleep monitoring of patient 6 years or older in a sleep lab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulpal debridement on tooth #6 (D3221) provided on April 
20, 2022. 
 
You asked the Plan to pay for pulpal debridement. You say that the debridement procedure was not covered. 
The Plan denied your request. The Plan says pulpal debridement (D3221) is not covered by your routine dental 
benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pulpal 
debridement on tooth #6 (D3221) provided on April 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge management (99239) billed for date of 
service May 3, 2022. 
 You asked the Plan to pay for hospital discharge care. You say that this service is supported in the medical 
records. The Plan denied your request. The Plan says only one hospital discharge code is payable per patient 
per hospital stay. Another discharge code has been billed for this enrollee for the same date of service and 
facility. The second discharge code billed is therefore not 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. The rules say that only one hospital discharge 
day management service is payable per patient per hospital stay. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, this code is a hospital 
discharge management code. The record shows that another discharge management code, 99238, has been 
billed for the same enrollee and date of service by a provider at the same facility. This means that the additional 
discharge management code is not payable. Based on this information, we decided that Medicare rules for 
coverage of hospital discharge care have not been met. Therefore, we decided that the Plan does not have to 
pay for hospital discharge management (99239) billed for date of service May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 6, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code must reflect the location in which 
the services were rendered. 
 
 
 
 
 
 
 
 
 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. Specifically, this claim was billed with POS code 31, which is 
incorrect as the enrollee was not an inpatient in the skilled nursing facility when the services were provided. 
Therefore, we decided that the Plan does not have to pay for the services provided on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 6, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code must reflect the location in which 
the services were rendered. 
 
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. Specifically, this claim was billed with POS code 31, which is 
incorrect as the enrollee was not an inpatient in the skilled nursing facility when the services were provided. 
Therefore, we decided that the Plan does not have to pay for the services provided on June 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Fam-trastuzumab (J9358) injection. 
 
You asked the Plan to pre-approve an injection. You say that the injection is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the use of Fam-trastuzumab for metastatic 
non-small cell lung cancer is not FDA approved or listed in the Medicare approved sources. 
 
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 an injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation indicates that the use of Fam-trastuzumab for metastatic non-small cell lung 
cancer is not FDA approved or listed in the Medicare approved sources; Drugdex and the National 
Comprehensive Cancer Network (NCCN) Drugs. The determination of medical necessity must be tailored to 
the individual patient and their unique clinical scenario. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Fam-trastuzumab (J9358) injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided from January 
22, 2021, to January 26, 2021. You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the place of 
service does not correspond to the facility bill. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The enrollees claim information shows that the place of service was not 
billed correctly for the services at issue. 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 
evaluation and management services provided from January 22, 2021, to January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral lumbar medial branch block. 
 
You asked the Plan to pre-approve a bilateral lumbar medial branch block. You say that the requested bilateral 
lumbar medial branch block is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for the requested bilateral lumbar medial branch block. 
 
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 bilateral lumbar medial branch block. Our reviewer says that the enrollee does not meet criteria for the requested bilateral lumbar medial branch 
block. Our physician reviewer found the records show the member has radicular pain, does not have reported 
facet arthropathy evident on imaging and has multiple herniated/bulging discs per magnetic resonance imaging 
(MRI) which encroach on the thecal sac, likely attributing to pain. The review has determined that the enrollee 
does not meet the criteria for the requested procedures. The requested medial branch blocks are not medically 
reasonable or necessary according to the coverage criteria established in the LCD. 
 
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 bilateral lumbar medial branch block have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a bilateral lumbar medial branch block.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93976 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for procedure code 93976. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93976 is bundled into payment for code 76856. 
 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 procedure code 93976 billed for date of service May 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64420 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code 64420. You say that the service at issue was billed as a separate 
and distinct service. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64420 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64420 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64420 billed for date of service March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 2, 2022 billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 0032U, & 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 2, 2022 billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 
0032U, & 0033U.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (17314) provided on January 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is an add-on code 
is is not 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 code the 
services is an add-on code and has not been billed with an appropriate primary procedure code. Primary 
procedure code 17313 is not payable in this case. 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 services (17314) provided on 
January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) with an oncologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you were diagnosed with prostate cancer in 
March 2022. Your provider has recommended you see the requested provider. The Plan denied your request. 
The Plan says you must receive your care from a 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 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 
an office visit (99204) with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy provided on 
May 23, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy with biopsy. You say that you did not consent 
to the biopsy. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $40 copayment for the colonoscopy with biopsy. This item/service falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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. Per 
the EOC, there is a $250 copayment for outpatient surgery, and a separate $40 copayment for specialist 
physician services may also apply. The file shows that there was no charge for the procedure itself, only the $40 copayment for the specialist serviTherefore, we decided that the Plan does not have to waive the 
copayment for the colonoscopy with biopsy provided on May 23, 2022.