Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on June 18, 2021. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code J1100 (32 Units) remains 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. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the procedure report documents 
"Dexamethasone 8mg was injected along the nerve root." This code is reported 1 ml = 1 unit. The 32 units reported cannot be verified in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services provided to the enrollee on June 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services a skin procedure provided to the enrollee on 
April 28, 2021. 
 
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 this code is not appropriate for the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 17999 is "Unlisted procedure, skin, mucous membrane 
and subcutaneous tissue." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report describes "Local 
flap reconstruction. In this case, there is a more appropriate code to report for this service. Services should be 
reported to the highest specificity, and therefore an unlisted procedure for service provided would not be 
covered.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services a skin procedure provided to the enrollee on April 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on November 4, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the imaging services. You say that these services were medically necessary and 
you are contracted with the facility where the enrollee was located.  You said that it is better for the patient to 
avoid transport in order to get these services. The Plan denied your request. The Plan says unauthorized, non-
plan care is not covered. 
 
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 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 imaging services provided on November 4, 2021, 
by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services (99232) provided to the enrollee on October 
22, 2021. 
 
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 there was active hospice enrollment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital services (99232) provided to the enrollee on October 
22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve imaging services provided to the enrollee on May 25, 
2021. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says this is a non-participating 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 
imaging services provided to the enrollee on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service October 18, 
2021. 
 
You asked the Plan to pay for procedure code 99072. You say that you believe the Plan underpaid this claim. 
The Plan denied your request. The Plan says no separate payment is made for this code. 
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99072 billed for date of service October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gene analysis panel test provided to the enrollee on August 
2, 2021.  
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this is denied due to the broad nature of the gene panel compared to the enrollee's diagnosis. 
 
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 the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a new diagnosis of liver cell carcinoma based on imaging and needle biopsy, but results 
suggest possible metastases from prior hx of breast cancer. A broad gene analysis panel test was performed and 
requested for coverage. However, the provided documentation did not show that staging has been performed of 
the cancer or type confirmed. Some tested genes in this broad panel would not likely lead to a significant 
change in clinical treatment or outcome compared to a focused gene panel which was not performed. 
Therefore, the requested Tempus Labs gene testing does not meet criteria. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for a gene analysis panel test provided to the enrollee on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided to the enrollee on June 1, 
2021. 
 
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 the available documentation does not indicate that the immunization was not injury related. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on 
June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99153) provided 
to the enrollee on September 23, 2021. 
 
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 the place of service was inappropriate for this procedure. 
 
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 99153 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found this procedure code is a technical code only, and would not be reported by the provider.  This code covers additional nurse or other healthcare 
professional monitoring the level of consciousness during the procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99153) provided to the enrollee on September 23, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine and administration charges you received 
on December 28, 2021. 
 
You asked the Plan to pay for the shingles vaccine. You say that you were not aware that this needed to be filed 
with Part D. You also said that you are unable to pay this bill. The Plan denied your request. The Plan says this 
vaccine is not covered under your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine and administration 
charges you received on December 28, 2021.  
 
Benefits for the shingles vaccine 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 drug testing services provided to the enrollee on May 10, 
2021. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code G0483 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 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 drug testing services provided to the enrollee on May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 18, 
2021. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 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 laboratory services provided to the enrollee on March 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 28, 
2021. 
 
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 the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 63685: 
 
Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 
 
CPT 95972: 
 
Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable 
parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) 
by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (eg, 
sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health 
care professional 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 63685, the 
operative report describes removal of old dorsal column stimulator paddle 2 and replacement with dorsal 
column stimulator 3, and therefore this procedure should be covered. In terms of CPT 95972, the operative 
report is of poor quality and difficult to read; however, documentation was not found in the report to support 
electronic analysis of implanted neurostimulator pulse generator/transmitter. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on August 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  
 
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 this procedure was billed without a National Correct Coding Initiatives (NCCI) allowed 
modifier. 
 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 71045 
is a column II code to column I code 36573. 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
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
December 4, 2021. 
 
You asked the Plan to pay for codes 99100 and 99140. You say that you provided medical records to support 
payment of this claim. The Plan denied your request. The Plan says these codes 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. 
 We find that CPT codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. This 
means that CPT codes 99100 and 99140 are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of codes 99100 and 99140 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 99100 and 99140 billed for date of service December 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on December 15, 2021. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider must submit a new claim with the correct type of bill. 
 
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 pay for self-administered drugs received on December 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99252 billed for date of service September 
30, 2021. 
 
You asked the Plan to pay for procedure code 99252. You say that this service was needed prior to surgery. 
The Plan denied your request. The Plan says this is not a Medicare-payable procedure code. 
 
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 99252 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99252 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99252 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99252 billed for date of service September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 25, 
2021. 
 
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 the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 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 laboratory services provided to the enrollee on May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air purifier and sanitizer (E1399). 
 
You asked the Plan to pre-approve an air purifier. You say that the air purifier is medically necessary. The Plan 
denied your request. The Plan says an air purifier and sanitizer is not considered Durable Medical Equipment 
(DME) by Medicare, more specifically because it does not serve a medical purpose and is not appropriate for 
use in the home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an air purifier and sanitizer (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 13, 
2021. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 Unit) remains not 
supported 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 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 drug testing services provided to the enrollee on April 13, 2021.