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

 
We decided that the Plan does not have to pay for code 99213 billed for date of service November 2, 2022. 
 
You asked the Plan to pay for code 99213. You say that code 99213 is a valid code, so this claim should be 
paid. The Plan denied your request. The Plan says code 99213 is not valid for outpatient hospital billing. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 99211-99215 will no longer be recognized 
for payment under the OPPS. In this case, you billed code 99213 on a facility (i.e., OPPS) claim.  Code 99213 
is not valid when billed on this claim type in an outpatient hospital facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99213 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99213 billed for date of service November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99236 billed for date of service December 
16, 2021. 
 
You asked the Plan to pay for procedure code 99236. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says the provided records do not support the service 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 99236 is: Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of high complexity.  Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 minutes are spent at 
the bedside and on the patient's hospital floor or unit. 
 
We asked our 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 99236. Our reviewer says that procedure 
code 99236 does not meet criteria for payment. Our reviewer found that the documentation available for review 
does not support that the presenting problems required medical decision of high complexity or that a 
comprehensive medical history was taken. 
 
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 99236 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99236 billed for date of service December 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 1, 2022, to 
March 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the NOA as 
required. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 1, 2022, to 
March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical facet joint injections. 
 
You asked the Plan to pre-approve cervical facet joint injections. You say that cervical facet joint injections are 
medically necessary. The Plan denied your request. The Plan says the requested cervical facet joint injections 
do not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 cervical facet joint injections. Our 
reviewer says that the requested cervical facet joint injections are not considered medically necessary in this 
case. Our physician reviewer found this 48-year-old enrollee had chronic neck pain post cervical fusion. The 
enrollee has had cervical epidural steroid injections and greater occipital nerve blocks. The enrollees radicular 
symptoms have improved. The enrollee is taking Duloxetine, Zanaflex and BuTrans for pain. The enrollees 
last magnetic resonance imaging was in 2016. There is no documentation of the enrollees cervical range of 
motion and response to facet axial loading. There is a lack of documentation of the enrollees physical 
examination and there is no recent imaging of her neck. Therefore, at this time, the request is deemed not 
medically reasonable and 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 cervical facet joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve cervical facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc NP. 
 
You asked the Plan to pre-approve VIA Disc NP. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 VIA Disc NP. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the VIA Disc NP procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of VIA Disc NP have not been met. Therefore, we decided that the Plan does not 
have to pre-approve VIA Disc NP.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spacers for teeth. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not covered under your supplemental dental 
policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve spacers for 
teeth.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0482 provided on October 18, 2022. 
 
You asked the Plan to pay for procedure code G0482. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that 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 
code G0482 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; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records show that 19 drug 
classes were tested, including, Amphetamines, Benzodiazepines, Buprenorphine, Cannabinoids-natural, 
Cocaine, Fentanyls, Gabapentin-non-blood, Heroin metabolite, Methadone, Methylenedioxyamphetamines, 
Methylphenidate, Opiates, Opioids and opiate analogs, Oxycodone, Phencyclidine, Pregabalin, Skeletal muscle 
relaxants, Tapentadol, and Tramadol. Based on this information, we decided that Medicare rules for coverage 
of procedure code G0482 have been met. Therefore, we decided that the Plan has to pay for procedure code 
G0482 provided on October 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an influenza vaccine (90662) provided on December 7, 2022. 
 
You asked the Plan to pay for the influenza vaccine. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 90662 is not supported in the medical record. Specifically, the claim was not billed 
using the correct codes per Local Coverage Article Billing and Coding: Medicare Preventive Coverage for 
Certain Vaccines (A54767).  
 
Based on this information, we decided that Medicare rules for coverage of the influenza vaccine have not been 
met. Therefore, we decided that the Plan does not have to pay for an influenza vaccine (90662) provided on 
December 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement services (procedure code 11012) rendered on 
October 18, 2022. 
 
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 Current Procedural Terminology (CPT) code 11012 (1 unit) 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. 
 
In this case, the CPT Code Manual definition of code 11012 is "Debridement including removal of foreign 
material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, 
subcutaneous tissue, muscle fascia, muscle, and bone." 
 
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 CPT code 11012 is not supported. 
The documentation does not contain evidence that debridement of an open fracture or dislocation was 
performed. 
 
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 debridement services (procedure code 11012) rendered on October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mobility scooter provided on November 1, 2022. 
 
You asked the Plan to pay for the mobility scooter. You say that the scooter should be covered as out-of-
network. The Plan denied your request. The Plan says that the provider is not enrolled in 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. 
 
A 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 pay for a mobility scooter provided on 
November 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Hydrocodone-Acetaminophen. 
 
You asked the Plan to pre-approve the Hydrocodone-Acetaminophen. You say that the drug should be covered. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 pre-approve the Hydrocodone-
Acetaminophen.  
 
Benefits for the Hydrocodone-Acetaminophen 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test and eye exams 
provided on October 28, 2022, to January 13, 2023. 
 
You asked the Plan to waive the copayment for outpatient diagnostic test and eye exams. You say that you 
disagree with the cost share. 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 $100 copayment for outpatient diagnostic tests/Medicare-covered ultrasound/Medicare-covered outpatient 
diagnostic, a $20 copayment for outpatient diagnostic tests/Medicare-covered outpatient diagnostic and a $50 
copayment for vision care.  
 
You have been asked to pay a $100 copayment for outpatient diagnostic test, a $50 copayment for outpatient 
diagnostic test and a $20 copayment for eye exams. However, you are only being asked to pay a $11.43 
copayment for the ultrasound which is less than the required amount. Also, a $45 copayment for one eye exam 
which is less than the required amount. The total amount you are being asked to pay is $126.43 ($50 + $45 + 
$11.43 + $20 =$126.43). 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 outpatient diagnostic test 
and eye exams provided on October 28, 2022, to January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service November 
22, 2022. 
 
You asked the Plan to pay for procedure code 20930. You say that these services were medically necessary. 
The Plan denied your request. The Plan says procedure code 20930 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 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service November 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653 and 87798 billed for 
date of service July 26, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87653 and 87798. You say that these services 
were reported appropriately and are supported in the medical record. The Plan denied your request. The Plan 
says the payment for these services is included in the payment for other services billed on this claim. 
 
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 codes 87150, 87481, 87653 and 87798 are column II codes to column I 
codes 87500 and 87150. In this case, codes 87481 and 87653 have not been billed with an appropriate modifier 
to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met for codes 87481 
and 87653. However, codes 87150 and 87798 were each 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 procedure codes 87150 and 87798. Our reviewer says that 
the 59 modifier is not supported to show that these services are distinct procedures. Our reviewer found that the 
laboratory report does not include documentation to support that these procedures were distinct or independent, 
such as performing the same procedure (that uses the same procedure code) for testing of a different specimen 
or different strain. Modifier 59 may be used when separate results are reported for different species or strains 
that are described by the same CPT code. The records do not support that these scenarios occurred for either 
code. 
 
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 codes 87150, 87481, 87653 and 87798 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653 and 87798 billed for 
date of service July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TERT promotion mutational analysis testing (81345) 
provided October 17, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that based on the information provided and 
supporting documentation that clearly shows medical necessity per Medicare criteria, you request overturn of 
the denial and reprocessing of the claim. The Plan denied your request. The Plan says this service is not 
covered. This expense does not meet the medically necessary requirements. 
 
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 81345 is TERT (telomerase reverse transcriptase) (eg, 
thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region). 
 
We find that CPT code 81345 is not supported in the medical record. Specifically, the claim was billed with a 
GZ modifier. The GZ modifier indicates that an Advance Beneficiary Notice (ABN) was not issued to the 
enrollee and that the item or service is expected to be denied as not reasonable and necessary. Claims submitted 
with a GZ modifier is automatically denied. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the TERT promotion mutational analysis testing (81345) provided October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services (procedure code J2001) rendered on 
August 2, 2022. 
 
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's a more appropriate unlisted Healthcare Common Procedure Coding System (HCPCS) 
code that should be used to bill for a lidocaine infiltration / injection through a non-intravenous route. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code 
J2001 is "Injection, lidocaine hcl for intravenous infusion, 10 mg." 
 
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 there is no evidence that an 
intravenous (IV) infusion of lidocaine was performed during this encounter. The record does not support J2001. 
There is a more specific code for the injection given. 
 
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 (procedure code J2001) rendered on August 2, 2022.