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

 
We decided that the Plan does not have to pay for procedure code 87798 at 13 units billed for date of service 
September 21, 2022. 
 
You asked the Plan to pay for the procedure code 87798. You say that the claim was correctly billed and should 
be paid. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 87798-59 
(13 Units) remains not supported. This code is included in Current Procedural Terminology (CPT) 87150; 
therefore, it cannot be separately reimbursed. 
 
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 87798 is a column II code to column I code 87150; however, 87798 
was billed with a modifier.  
 
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 procedure code 87798. Our reviewer says that the 
documentation does not support payment for the units of code 87798. Our reviewer found CPT 87798 was 
reported with modifier -59 for distinct procedural service; however, the laboratory report does not include 
documentation to support a separate service, and therefore, modifier 59 cannot be verified. 
 
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 procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 at 13 units billed for date of service September 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
November 30, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
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/Medicare-covered outpatient surgery. 
 
You have been asked to pay a $250 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered 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 an outpatient surgery provided on November 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Padcev (J9177). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee needs this drug for their rare 
cancer diagnosis. You say that the enrollee was actively treated with Carboplatin and taxol but has had disease 
progression. You say that the enrollee was also previously treated with Gemzar, Piqray, 5-Fu, Paclitaxel, 
Ifosfamide, and Cisplatin along with radiation. The Plan denied your request. The Plan says the requested use 
of Padcev is not approved by the FDA for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer found the requested use of Padcev is not FDA-approved for the enrollees diagnosis. The use is not supported 
by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services (CMS)-approved medical journal 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Padcev (J9177).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
January 2, 2023. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 01, 2020. The Plan 
denied your request. The Plan says that this code must be billed by the OTP facility on a facility claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on January 2, 2023.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 9, 2022, 
through June 16, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says these services are not medically necessary 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was admitted in stable condition and there was not a reasonable 
expectation that the care would need to span two or more midnights. The inpatient admission is not medically 
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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from June 9, 2022, through June 16, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room service provided on 
December 2, 2022, and the specialist office visit provided on December 15, 2022. 
 
You asked the Plan to waive the copayments for the emergency room visit and the specialist office visit. You 
say that your surgery was rescheduled, and you should not have to pay for these services. 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 $90 
copayment for each emergency room visit. Your contract with the Plan also clearly says that you must pay a $40 copayment for each specialist office visit for Medicare-covered services. 
 
You have been asked to pay a $90 copayment for the emergency room visit provided on December 2, 2022. 
This item/service falls within the emergency care benefit category. You have also been asked to pay a $40 
copayment for the specialist office visit provided on December 15, 2022. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 copayments for the emergency room service provided on December 2, 2022, and the specialist 
office visit provided on December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the vaccines provided on August 31, 2020. 
 
You asked the Plan to waive the deductible for the vaccines. You say that you would like to appeal these 
charges. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to out-of-network immunizations.  
 
The item or service you asked the Plan to waive the deductible for falls within the immunizations benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to out-of-network immunizations. This cost sharing is a contractual obligation that 
had not been met at the time the vaccines was received on August 31, 2020. Therefore, we decided that the 
Plan does not have to waive the deductible for the vaccines provided on August 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a kidney procedure provided on November 
30, 2022. 
 
You asked the Plan to waive the copayment for a kidney procedure. You say that you do not think you should 
be responsible for this 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 $40 
copayment for in-network specialist physician outpatient surgery services. 
 
You have been asked to pay a $40 copayment for a kidney procedure. This item/service falls within the in-
network specialist physician outpatient surgery services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for a kidney procedure provided on November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office evaluation and management (EM) services 
provided on October 31, 2022, billed with code 99205. 
 
 
You asked the Plan to pay for the EM services as billed. You say that the code is correct and should be paid. 
The Plan denied your request. The Plan says this code 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 99205 is Office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter. 
 
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 EM services as billed. Our reviewer says 
that the code billed in this case is not supported. Our reviewer found a History and physical examination of 
10/31/22 was reviewed. While all of the elements of a History and Physical exam are present, there is a lack of 
in-depth detail of physical findings, such as detailed range of motion, motor and sensory testing. There is no 
documentation of complex medical decision making. 
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the office evaluation and management (EM) services provided on October 31, 
2022, billed with code 99205.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Libtayo (J9119). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says this would not be appropriate. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the requested use of Libtayo is not FDA-approved for the enrollees diagnosis as it has not yet received a 
hedgehog pathway inhibitors or stated as having a contraindication to this. The use is not supported by one of 
the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS)-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Libtayo (J9119).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low osmolar contrast material (Q9966) provided on 
October 3, 2022. 
 
You asked the Plan to pay for the service. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the records submitted do not support procedure code Q9966-Low osmolar contrast 
material, 200-299 mg/ml iodine concentration, per ml. 
 
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 Q9966 is ow osmolar contrast material, 200-299 mg/ml 
iodine concentration, per ml. 
 
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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The procedure report documents, "After pulling back on the syringe 
plunger to assure that no blood or CSF flow was seen, 1.0 CC of Omnipaque 180mg/mL was injected using 
live fluoroscopy, to maximize safety, to confirm needle placement, and to assure that there was no vascular or 
subdural / subarachnoid flow". Code Q9966 would be reported for 200-299 mg/ml. In this case, the billed code 
Q9966 is not supported, and therefore, cannot be verified. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the low osmolar contrast material (Q9966) provided on October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services 
provided on August 31, 2022, billed with code 99236. 
 
You asked the Plan to pay for the EM services as billed. You say that this was billed correctly. The Plan denied 
your request. The Plan says the code at issue 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 99236 is Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and 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 presenting problem(s) requiring admission are of high severity. Typically, 55 
minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 EM services as billed. Our reviewer says 
that the documentation does not support the billed code. Our reviewer found the member is a 91-year-old male 
with a medical history including hypertension, cardiac disease, diabetes mellitus, chronic kidney disease and 
myelodysplastic syndrome who presented to the emergency department on 08/31/2022 with bleeding of a 
wound on the right scalp. He required pressure to the scalp for resolution of the bleeding. His hemoglobin was 
6.2 and he was transfused 2 units of blood then discharged. Of note, the member is chronically anemic and was 
planned the same day for an outpatient blood transfusion. The documentation available for review does not 
support that the presenting problems were of high severity or that the medical decision was of high complexity. 
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient evaluation and management (EM) services provided on August 31, 
2022, billed with code 99236.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prolonged service in the inpatient or observation setting 
(99356) provided on September 14, 2022. 
 
You asked the Plan to pay for the service. You say that the medical records support the billing of code 99356. 
The Plan denied your request. The Plan says the medical records do not support the billing of code 99356. 
 
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 99356 is prolonged service in the inpatient or observation 
setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for 
inpatient or observation Evaluation and Management service). 
 
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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. Evaluation and management service provided on September 14, 2022, 
does not include documentation of prolonged service with time; therefore, cannot be verified. CPT 99356 is a 
timed procedure code, and in this case, time is not documented. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the prolonged service in the inpatient or observation setting (99356) provided on September 14, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal ankle foot system, microprocessor-
controlled feature, dorsiflexion and/or plantar flexion control, includes power source. 
 
You asked the Plan to pre-approve the requested ankle-foot system. You say that the requested ankle-foot 
system should be approved. The Plan denied your request. The Plan says the requested ankle-foot system is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage may be offered for advanced ankle-foot 
systems when these are reasonable and necessary. 
 
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 requested ankle-foot system. Our 
reviewer says that the requested ankle-foot system is not shown to be medically necessary. Our physician 
reviewer found an endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source exceeds the patient's medical needs and is not medically 
necessary. The treating medical physician provider documentation does not support that the patient's activities 
and functional needs require the Blatchford Elan Microprocessor foot over a less advanced foot.  
 
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 requested ankle-foot system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an endoskeletal ankle foot system, microprocessor-controlled feature, 
dorsiflexion and/or plantar flexion control, includes power source.