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

 
We decided that the Plan does not have to reimburse you for the raised toilet seat (E0244) purchased June 3, 
2022 from an non-Medicare certified provider. 
 
You asked the Plan to reimburse you for the raised toilet seat. You say that you were advised to purchase the 
raised toilet seat to assist in standing and decrease falls that are occurring after using the toilet. The Plan denied 
your request. The Plan says the item was purchased from a supplier who is not under contract with the health 
Plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the raised toilet seat (E0244) 
purchased June 3, 2022 from an non-Medicare certified provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D rendering with interpretation of CT scan provided on 
January 29, 2022. 
 
You asked the Plan to pay for the 3D imaging. The Plan denied your request. The Plan says there was no 
documentation of an order for the 3D image nor documentation by the interpreting physician that the 3D 
interpretation was necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for hospital based services (inpatient/outpatient), 
it is expected that there should be an order for the 3D image. In the absence of the order for the 3D image, if 
the hospitals interpreting physician deems that the 3D interpretation is needed, he or she should clearly state in 
the interpretation the medical necessity for this separate service, in addition to the base procedure.  
 
We looked at the file and Medicare rules. The records provided do not contain an order for the 3D imaging, nor 
do they contain documentation that the interpreting physician deemed the 3D interpretation as medically 
necessary. Based on this information, we decided that Medicare rules for coverage of the 3D imaging have not 
been met. Therefore, we decided that the Plan does not have to pay for the 3D rendering with interpretation of 
CT scan provided on January 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 4, 2022, and billed 
with codes 81162, 81201, 81314, 81321, 81334, 81351, and 81479. 
 
You asked the Plan to pay for genetic testing. You say that this is supported in the records. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 4, 
2022, and billed with codes 81162, 81201, 81314, 81321, 81334, 81351, and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
 The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules 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 code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing billed with code 83789.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you have submitted records to support the medical 
necessity of this claim. The Plan denied your request. The Plan says the rendering provider is a non-
participating provider, and there is no referring provider involved in these services. The Plan also says that they 
did not authorize any services for this 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 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 9, 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 procedure code 99072 billed for date of service January 16, 
2022. 
 
You asked the Plan to pay for procedure code 99072. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says procedure code 99072 is considered 
bundled and 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 procedure code.  
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure 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 January 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination of the abdomen provided on 
November 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a radiologic examination of the abdomen. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the rendering provider is a non-participating 
provider. The Plan also says that they did not authorize any services for this 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 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 radiologic examination of the abdomen provided 
on November 27, 2021, 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 transitional care management services (99496), routine 
blood draw (36415), office visit (99213), influenza vaccine (90688), and administration (G0008) provided from 
October 12, 2021, to October 26, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services should be covered. The Plan 
denied your request. The Plan says the claims are related to a motor vehicle accident. The Plan also says that 
you need to bill the No-Fault insurance first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the physician services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the transitional care management services (99496), routine blood 
draw (36415), office visit (99213), influenza vaccine (90688), and administration (G0008) provided from 
October 12, 2021, to October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 8, 2022. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says you billed 
with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing 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 drug testing services provided on June 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires extended 
hospitalization and close physician monitoring. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 
 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve radiofrequency ablation services. You say that radiofrequency ablation 
services are medically necessary due to the enrollee's spondylosis with myelopathy in the cervical region. The 
Plan denied your request. The Plan says Medicare's rule for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation services are covered when 
they are medically necessary for certain clinical indications.  
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 radiofrequency ablation services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has 
had some overlap in treatment of the cervical spine. There is no documentation that she had 2 MBBs at the left 
C2-C3/C3-C4 levels that have provided 80% pain relief. The review has determined that the criteria for 
coverage have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service January 1, 
2022, to January 28, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service January 1, 2022, to January 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services provided on April 22, 2022, billed 
with code 76999. 
 
You asked the Plan to pay for the ultrasound as billed. You say that there is no procedure code which 
accurately describes the imaging that was performed. As such, the use of code 76999 is correct. The Plan 
denied your request. The Plan says a different CPT code can be used to report this testing. 
 
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 76999 is Unlisted ultrasound procedure (eg, diagnostic, 
interventional). 
 
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 ultrasound as billed. Our reviewer says that the billed 
code is not supported by the records. Our reviewer found the procedure report describes an ultrasound of the 
left groin, and in this case, there is a more appropriate code to report for service provided. The procedure report 
documents "Realtime grayscale and color Doppler ultrasound imaging was directed to left groin at site of interest". Therefore, CPT 76999 cannot be verified, as there is a higher specificity code to report for service 
provided. 
 
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 ultrasound as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the ultrasound services provided on April 22, 2022, billed with code 76999.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgery for your neck (fusion) (CPT code(s): 22551, 
22845, 22853 and 20930). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says they do not see that your magnetic resonance imaging (MRI) shows compression of 
your spinal cord or pinched nerves. The Plan states they do not see on the MRI that your spine condition has 
become worse, and they do not see that your spine condition causes problems with your activities of daily 
living. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested C4-5 anterior cervical 
microdiscectomy and fusion (CPT code(s): 22551, 22845, 22853, and 20930), in this case, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the surgery for your neck (fusion) (CPT code(s): 22551, 22845, 22853 and 20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the foot orthotics (L3020 x 2) and the sales 
tax (S9999) purchased on March 7, 2022 and March 25, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not covered by 
the Plan or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Additionally, with the exception of the situations described above, orthopedic footwear billed using 
code L3020 will be denied as non-covered.  Therefore, we decided that the Plan does not have to issue reimbursement for the foot orthotics (L3020 x 2) and 
the sales tax (S9999) purchased on March 7, 2022 and March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on March 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0483 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 G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, there are no documented 
laboratory results. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on 
March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) sensor (K0553) 
provided on January 3, 2022. 
 
You asked the Plan to pay for a CGM sensor. You say that the item at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the available records do not discuss the item at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a continuous glucose monitor (CGM) sensor (K0553) provided on January 3, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 11, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the attached documents should be reviewed 
for medical necessity as the services were necessary for the enrollee's care. The Plan denied your request. The 
Plan says procedure code 01844 has been paid. The Plan also says procedure code 99100 is considered bundled 
and 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 procedure code. 
  We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 11, 2022.