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

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service February 7, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan to reconsider 
their denial. The Plan denied your request. The Plan says payment for code 83789 is bundled into payment for 
codes G0481 and 80307. 
 
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 state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that code 83789 is a column II code to column I code G0481 and 80307. While 
code 83789 was billed with modifier -59, the medical records provided do not show that the service billed with 
the -59 modifier is a distinct procedural service. In addition, this code is not separately reimbursed when billed 
for specimen validity testing on urine specimens utilized for drug testing. 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 83789 billed for date of service February 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the self-administered drug (A9270) 
provided on May 26, 2022. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug provided is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to issue reimbursement for the self-
administered drug (A9270) provided on May 26, 2022.  Benefits for this item may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you do not need an authorization. The Plan denied 
your request. The Plan says this provider is not a network provider with the Plan and the services were not 
referred by a network provider or rendered in an in-network facility. The Plan also says that these services were 
not approved in advance. 
 
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 an office visit provided on June 1, 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 the technical component (TC) and supplies used during 
intraoperative neuromonitoring (IONM) provided on November 22, 2021. 
 
You asked the Plan to pay for the TC and supplies for IONM services. You say that you own the equipment 
and employ the technician, not the hospital. You state that the hospital cannot be reimbursed for services the 
hospital did not perform. The Plan denied your request. The Plan says no separate payment can be made for the 
billed services.  
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
Additionally, the rules say that for services provided to a hospital inpatient or outpatient, the TC of diagnostic 
testing is included in payment made to the facility. 
 
We looked at the file and Medicare rules. Though you may own the equipment and employ the technician, 
Medicare does not make separate payment for these non-physician services and items. Payment must be sought 
from the facility. Based on this information, we decided that Medicare rules for coverage of the TC and 
supplies for IONM services have not been met. Therefore, we decided that the Plan does not have to pay for the 
technical component (TC) and supplies used during intraoperative neuromonitoring (IONM) provided on 
November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on May 3, 0222. 
 
You asked the Plan to pay for the lab services. You say that the medical records support medical necessity. The 
Plan denied your request. The Plan says the testing is not a benefit without documentation from the treating 
provider. 
 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. In this case, there are no medical records from the treating physician 
to show the testing was ordered for a specific medical problem. There are no records to show the physicians 
intent for the testing to be performed. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing 
services provided on May 3, 0222.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy evaluation and management visit in an 
assisted living facility provided on February 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a psychotherapy and rest home visit. You say that the provider relies on the 
assisted living facility staff to verify enrollee eligibility and to obtain prior authorizations. The Plan denied your 
request. The Plan says the services were not approved in advance and were neither urgent nor emergent. The 
Plan also says that the services rendered were not Plan Directed Care and cannot be approved. 
 
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 a psychotherapy evaluation and management visit 
in an assisted living facility provided on February 25, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one additional hour per day, seven days per week, of 
home health aide (HHA) services. 
 
You asked the Plan to pre-approve one additional hour per day, seven days per week, of HHA services. The 
Plan denied your request. The Plan says the enrollee does not qualify for HHA services four hours a day, seven 
days a week because it is considered custodial care. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 one additional hour per day, seven days 
per week, of HHA services. Our reviewer says that the requested HHA services are not medically necessary or 
reasonable. Our physician reviewer found the enrollee does not have documented home health skilled nursing 
needs. Our reviewer found that the enrollee does not have documented home health skilled therapy needs. Our 
physician reviewer also found that it is not shown that HHA services are required to assist in the treatment of 
illness or injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of one additional hour per day, seven days per week, of HHA services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve one additional hour per day, seven 
days per week, of home health aide (HHA) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77427 billed for date of service October 29, 
2020. 
 You asked the Plan to pay for procedure code 77427. You say that this service is supported in the medical 
records provided. The Plan denied your request. The Plan says payment for code 77427 is bundled into 
payment for code 77770. 
 
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 77427 
is a column II code to column I code 77770. 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 77427 billed for date of service October 29, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on April 12, 2022. 
 You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the date of 
service is inconsistent with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. In this case, there were insufficient medical records to show that the 
Medicare coverage criteria have been met regarding the billed date of service provided on the claim. Based on 
this information, we decided that Medicare rules for coverage of the testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the gene panel testing provided on April 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate (J8610). 
 
You asked the Plan to pre-approve Methotrexate. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by their Medicare Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methotrexate (J8610).  
 
 
 
 
 
  
Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional inpatient psychiatric services. 
 
You asked the Plan to pre-approve the additional inpatient psychiatric care. You say that it is felt that this 
should be approved based on the medical necessity of this level of care for the enrollee. The Plan denied your 
request. The Plan says Medicare does not cover more than 190 days of inpatient psychiatric care during an 
enrollee's lifetime. This limit has previously been reached. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a lifetime maximum of 190 days on 
inpatient psychiatric hospital services available to any beneficiary. 
 
We looked at the file and Medicare rules. Review of the file shows that as of September 13, 2022, all 190 
inpatient psychiatric days have been used. Based on this information, we decided that Medicare rules for 
coverage of the additional inpatient psychiatric care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional inpatient psychiatric services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine PCR (polymerase chain reaction) testing provided on 
January 12, 2022. 
 
You asked the Plan to pay for urine PCR testing. You say that this service is covered by Medicare and was 
denied as experimental in error. The Plan denied your request. The Plan says the standard of care for the 
evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. The PCR testing is 
considered unproven and 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 pay for urine PCR testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the standard of care for the evaluation of urinary tract infection is urinalysis with urine culture and sensitivity. The PCR testing is considered unproven and not medically necessary. The review has 
determined that the items/services at issue in this case are 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 urine PCR testing have not been met. Therefore, we decided that the Plan does 
not have to pay for urine PCR (polymerase chain reaction) testing provided on January 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided on April 12, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
documentation does not include records for the provider. 
 
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 code 99223 is not supported. The records show that code 99223 was previously billed for the 
date of the enrollees inpatient admission. The rules say that follow up visits should be billed as subsequent 
hospital care visits.  
 Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the hospital services provided on April 12, 
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 May 14, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. 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. 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 May 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an excision or destruction (eg, laser), intranasal lesion 
(30117) using the RhinAer procedure. 
 
You asked the Plan to pre-approve the RhinAer procedure. You say that the use of a radiofrequency ablation 
stylus is medically necessary for treatment of the enrollee's condition. You say that the enrollee has failed to 
sustain long-term benefits form conventional treatments. You also say that this has impacted their quality of 
life. The Plan denied your request. The Plan says the requested service is not medically reasonable or 
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 the RhinAer procedure. Our reviewer 
says that the requested RhinAer procedure is not considered medically reasonable and necessary in this case.  Our physician reviewer found there is insufficient literature to support the safety and efficacy of the requested 
service for your condition. Therefore, the reviewer found that the requested procedure 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 the RhinAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an excision or destruction (eg, laser), intranasal lesion (30117) using the RhinAer 
procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services (procedure code 75743) provided to the 
enrollee on April 26, 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 procedure code 75743-26-59 cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 pay for the services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
already paid procedure - CPT 37184 - would include bilateral pulmonary angiography both before and after the 
bilateral thrombectomy. Therefore, the denied code - CPT 75743 - should not have been billed separately 
according to the guidelines. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for imaging services (procedure code 75743) provided to the enrollee on April 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Forteo. 
 
You asked the Plan to pre-approve Forteo. The Plan denied your request. The Plan says this drug is not covered 
for the enrollee's condition by their Medicare Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Forteo.  
 
Benefits for Forteo may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0481, 83789) provided on March 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. In addition, code 83789 in this case is used for specimen validity testing which is not separately 
payable. 
 
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. Medicare rules also say that providers performing validity testing on urine specimens utilized for drug 
testing should not separately bill the validity testing. 
 
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. In addition, we find that the 
testing described by code 83789 is considered specimen validity testing which is not separately payable. 
Therefore, we decided that the Plan does not have to pay for lab services (G0481, 83789) provided on March 
31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgical visit provided on June 06, 2022. 
 
You asked the Plan to waive the copayment for surgical visit. You say that the procedure was considered 
preventative to identify and remove any cancerous or precancerous lesions. You say that according to section 
2713 of the affordable care act, this procdure is not subject to a copayment. 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 $250 
copayment for outpatient surgery. 
 
You have been asked to pay a $250 copayment for surgical visit. This item/service falls within the outpatient 
surgery 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 surgical visit provided on 
June 06, 2022.