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

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87500, 87640, 
87641, and 87798 for date of service March 8, 2023. 
 
You asked the Plan to pay for the laboratory services billed with codes 87500, 87640, 87641, and 87798. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with codes 87500, 87640, 87641, and 87798 for 
date of service March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 29, 2023. 
 
You asked the Plan to pay for an office visit. You say that this should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 29, 2023.
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 the enrollee needs intensive therapy to regain daily 
optimal functioning and independence. The enrollee meets the criteria for an IRF admission. The Plan denied 
your request. The Plan says IRF care is not reasonable and necessary.  
 
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 the complexity of the patient's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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. Medically necessary care can be provided in a different 
level of care.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057), abutment
support crown (D6058) for teeth #11 and 12, and pontics (D6245) for teeth #13 and 14.

You asked the Plan to pre-approve a custom fabricated abutment, abutment support crown and pontics. You
say that you are appealing the denied dental services because they need to be completed. The Plan denied your
request. The Plan says that your benefit for the implants has been exhausted and the pontics cannot be approved
because you do not have the necessary supports.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for pontics for teeth
#13 and 14. Our Medical Director states that the available documentation does not support that there is
sufficient support available for the requested pontics. Our Medical Director found that your condition does not
meet criteria for coverage of the pontics.

We looked at this physician's review, the file, and Medicare rules. The record shows the Plan approved a
custom fabricated abutment (D6057) and abutment supported crown (D6058) for teeth #8 and 9; therefore,
your benefit for implant services was exhausted on the date of approval of February 6, 2023. Based on this
information, we decided that the Plan's rules for coverage of a custom fabricated abutment, abutment support
crown and pontics have not been met. Therefore, we decided that the Plan does not have to pre-approve a
custom fabricated abutment (D6057), abutment support crown (D6058) for teeth #11 and 12, and pontics
(D6245) for teeth #13 and 14.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 24, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on May 1, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on May 1, 
2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 0245U-59 and 88381 provided August 11, 
2023. 
 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 services are not supported by the records. 
 
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 88381 is microdissection (that is, sample preparation of 
microscopically identified target); manual. 
 
In this case, we have confirmed that code 0245U is a column II code to column I code 0018U; however, 0245U 
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 services. Our reviewer found 0245U-59 is not supported 
as a separately identifiable procedure. These services are included in approved code 0018U. Furthermore, code 
88381 is not supported. The documentation does not contain a description of manual microdissection. 
 
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 procedure codes 0245U-59 and 88381 provided August 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the cystourethroscopy procedure, and the 
onabotulinumtoxina injection provided on August 11, 2023. 
 
You asked the Plan to reduce the cost share for the cystourethroscopy procedure and the injection. You say that 
you only had a $20 copayment for this procedure in the past. 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 $20 
copayment for surgery services provided in a specialists office. Your contract with the Plan also clearly says 
that you must pay 20% coinsurance for Medicare Part B covered drugs. 
 
You have been asked to pay a $20 copayment for the cystourethroscopy procedure. This item/service falls 
within the physician/practitioner services, including doctor's 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.  
 
You have also been asked to pay $255.60, which is 20% coinsurance of the allowed amount for the injection 
($1,278 allowed amount x 20% = $255.60). This item/service falls within the Medicare Part B prescription 
drugs benefit category. You have been asked to pay a total of $275.60 ($20 copayment + $255.60 coinsurance 
= $275.60). 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 reduce the cost share for the cystourethroscopy procedure, and the 
onabotulinumtoxina injection provided on August 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0483 for date of service October 22, 2022. 
 
You asked the Plan to pay for code G0483. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are 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 drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the laboratory results 
provided do not align with the billed date of service. The documentation shows a required collection date of 
October 19, 2022, accessioned date of October 22, 2022, and no signature date but a report date of October 26, 
2022. Therefore, the date of service on the claim is not supported with the medical records provided. Based on 
this information, we decided that Medicare rules for coverage of code G0483 have not been met. Therefore, we 
decided that the Plan does not have to pay for code G0483 for date of service October 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99232 for date of service May 
24, 2023, to May 25, 2023. 
 
You asked the Plan to pay for procedure codes 99223 and 99232. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are 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 find that CPT codes 99223 and 99232 are not supported in the medical record. Specifically, the submitted 
medical records include an initial hospital or observation care, evaluation and management note and a 
subsequent hospital inpatient or observation care, evaluation and management note; however, the notes do not 
include the actual date of service. The charted date, dictated date, transcribed date, admit date, signature date or 
discharge date is not sufficient and cannot be used as the actual date of service. In addition, the submitted medical records do not include the enrollee's name. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 99223 and 99232 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 99223 and 99232 for date of service May 24, 2023, to May 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81432) provided on February 7, 
2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this claim cannot be processed until an Explanation of Benefits from 
the primary insurance is received. 
 
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 made several 
attempts to obtain information showing that the primary insurance has processed the claim. As the secondary 
insurer, the Plan cannot be held responsible for the laboratory 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 laboratory services 
(81432) provided on February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care provided on September 22, 
2023. 
 
You asked the Plan to waive the copayment for vision care. 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 $35 
copayment for vision care. 
 
You have been asked to pay a $35 copayment for vision care. This item/service falls 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 waive the copayment for vision care provided on 
September 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home or residence visit provided on August 1, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home or residence visit. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit when provided by an 
OON 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 the home or residence visit provided on August 1, 
2023, 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 codes 96450 and 77003 billed for date of service 
July 17, 2023. 
 
You asked the Plan to pay for procedure codes 96450 and 77003. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says code 96450 was not billed with the required 
modifier to allow separate payment within the global surgery period. Code 77003 is an add-on code billed 
without an appropriate primary procedure code. 
 
The Plan must follow Medicare rules. The rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. Medicare rules also say that many services within the 
postoperative period are considered to be included within payment for the global surgical procedure. Two 
exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -
24, and unrelated surgical procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. Procedure code 96450 is within the global surgery period of code 
36561 provided on July 17, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for procedure code 
96450 have not been met. Additionally, we have confirmed that code 77003 is an add-on code and has not been 
billed with an appropriate, payable primary-procedure code. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96450 
and 77003 billed for date of service July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 
05, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. 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 $15 
copayment for physician/practitioner services/specialists office. 
 
You have been asked to pay a $15 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialists office 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 specialist office visit provided on May 05, 2023.
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 LTACH services are medically 
necessary for the recovery of the enrollee. The Plan denied your request. The Plan says the enrollee is receiving 
adequate care at their current facility, and they are currently unstable for transfer. 
 
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 given the ongoing treatment for diabetes insipidus, hypernatremia, 
lethargy, persistent shortness of breath, and lack of tracheostomy, it is not safe to transfer the enrollee. The 
enrollee is receiving the required care at the current facility being offered by the health Plan. 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.