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

 
We decided that the Plan does not have to pay for the electrocardiogram (CPT code 93010) provided on 
November 10, 2021. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the records submitted do not indicate that two separate services were performed/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. 
 
CPT code 93010 has an associated procedure in history for the same date of service and is not allowed for 
payment without an appropriate modifier. 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 
electrocardiogram (CPT code 93010) provided on November 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination (71046) provided on February 17, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiologic examination provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-
network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the radiologic examination (71046) provided on 
February 17, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The rules say that laboratories shall not report multiple individual CPT codes describing the component test 
results. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. 
  
 
 Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 16, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on October 14, 
2021. 
 
You asked the Plan to pay for code 0012M. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the CxBladder testing (0012M) provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical or thoracic facet injection (64490, 64491, 
64492). 
 
You asked the Plan to pre-approve injections. You say that the requested injections are medically necessary. 
The Plan denied your request. The Plan says the requested injections are 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 pre-approve injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the prior results of these blocks do not support repeating them. The records show that you only 
had a 40% improvement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a cervical or thoracic facet injection (64490, 64491, 64492).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 87150) provided on 
September 10, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. The Plan states CPT code 87150 was billed, but 
there is a more appropriate Proprietary Laboratory Analyses (PLA) code (0097U) that should be used to bill for 
the service provided; therefore, the billed code cannot be verified. 
 
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 laboratory service 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 the laboratory service (CPT code 87150) provided on September 10, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter Covid-19 test, purchased on January 4, 
2022. 
 
You asked the Plan to pay for the over-the-counter Covid-19 test. You say that the item should be covered. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the over-the-counter Covid-19 test have not been met. Therefore, we decided that the Plan does not 
have to pay for the over-the-counter Covid-19 test, purchased on January 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab for the enrollee. 
 
You asked the Plan to pre-approve pembrolizumab. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this treatment is used for the enrollee's cancer only if a certain marker is found 
using special testing. 
 
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 pembrolizumab. Our reviewer says that 
pembrolizumab is not medically reasonable and necessary. The requested use of pembrolizumab is not FDA-
approved for the enrollees diagnosis. The use of pembrolizumab is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer 
found the enrollee's condition does not meet criteria for coverage of pembrolizumab. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pembrolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pembrolizumab for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781) deluxe frames (V2020) anti-
reflective lens (V2750) polycarbonate lens (V2784) purchased April 6, 2021 
 
You asked the Plan to pay for the vision services. You say that you thought that you would have received some 
of your money back since you have a $200 vision benefit with the Plan and you paid out of your pocket $239. 
The Plan denied your request. The Plan says the vision benefit has been exhausted and the correct cost share 
has been applied per the Evidence of Coverage 
 
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 for all 
costs over and above the $200 allowance amount.  
 You have been asked to pay $268.80 ($239 + $29.80) for the vision services. The Plan had applied the $200 
vision benefit which was applied to CPT codes V2020, V2750 and part of V2784 as the benefit exhausted. The 
vision services fall within the Vision care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for progressive 
lenses (V2781) deluxe frames (V2020) anti-reflective lens (V2750) polycarbonate lens (V2784) purchased 
April 6, 2021
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT 
code 70450) and cerebral perfusion analysis using computed tomography with contrast administration, 
including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood 
volume, and mean transit time (CPT code 0042T) provided on December 1, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 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. Furthermore, review of the file shows that the enrollee's medical records do not show they meet 
the criteria for cerebral perfusion analysis using CT with contrast (CPT code 0042T). 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 CT scan, head or brain; without contrast material (CPT code 70450) and cerebral perfusion analysis 
using computed tomography with contrast administration, including post-processing of parametric maps with 
determination of cerebral blood flow, cerebral blood volume, and mean transit time (CPT code 0042T) 
provided on December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home COVID-19 test (U0004) purchased February 11, 
2022. 
 
You asked the Plan to pay for the home COVID-19 test. You say that you were informed that the COVID home 
test kits are covered by insurance. The Plan denied your request. The Plan says this item is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the home 
COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for the home 
COVID-19 test (U0004) purchased February 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the patient was admitted for a fall, acute kidney injury, urinary tract infection, and metabolic encephalopathy. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In 
conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service November 
16, 2021. 
 
You asked the Plan to pay for procedure code 99284. You say that code 99284 should have been paid as billed. 
The Plan denied your request. The Plan says procedure code 99284 was not supported in the medical record, so 
payment was downgraded to reflect code 99283 instead. 
 
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 99284 is emergency department visit, detailed history; 
detailed examination; and medical decision making of moderate complexity. 
 
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 procedure code 99284. Our reviewer says that procedure 
code 99284 is not supported in the medical record. Our reviewer found evaluation and management services 
provided support an expanded problem focused history; comprehensive exam and medical decision making of 
moderate complexity per guidelines. Emergency room visits require 3 key components.  In this case, code 99283 is a more appropriate code to 
report.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99284 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99284 billed for date of service November 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided on October 26, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that because this enrollee fatigues easily and has 
difficulty being transported, this procedure is required to be provided onsite, by the physician assigned to 
provide care to this enrollee. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
 
  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit provided on October 26, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82656, 83520, 83631) 
provided on March 24, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
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 laboratory 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 the laboratory services (CPT code(s): 82656, 83520, 83631) provided on 
March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic thoracic spine injection (62320) provided 
November 29, 2021. 
 
You asked the Plan to pay for the injection services. You say that this treatment is a part of a comprehensive 
pain management program that has been implemented since all conservative measures including more 
aggressive therapies such as surgical intervention has failed. The Plan denied your request. The Plan says 
medical necessity cannot be established for the service provided. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of therapeutic thoracic spine injection 
(62320) provided November 29, 2021. have been met. the records provided are undated and unsigned. The 
provider has not submitted the required clinical records to support the medical necessity of the service for the 
date of service requested. The Plan made several attempts to obtain the needed medical records from the 
provider without success.. Therefore, we decided that the Plan does not have to pay for therapeutic thoracic 
spine injection (62320) provided November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subarachnoid injection (62320) provided on November 22, 
2021. 
 
You asked the Plan to pay for injection procedure. You say that this procedure code is covered by Medicare 
without a diagnosis code limitation. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the documentation does not establish the necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that code 62320 is not covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of injection procedure have not been met. Therefore, we decided that the Plan does not have to pay 
for a subarachnoid injection (62320) provided on November 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says it is not reasonable to expect that you will be able to fully benefit from the 
intensity of services of an IRF. You can safely receive services in another setting such as in your skilled 
nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that your medical problems are stable and you have no complex nursing or 
rehabilitation needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.