Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the outpatient surgery and physical therapy provided 
out of the country from February 26, 2023, through May 3, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the services 
provided were not emergent in nature; therefore, they are not payable.  
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.  
 
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 issue reimbursement for these services. Our 
reviewer says that the services provided were medically necessary. Our physician reviewer found that you were 
being treated for a proximal humerus fracture. This fracture was a result of a fall that occurred on February 26, 
2023. There is no way to predict a fall with a fracture. In this case, the computed tomography study showed 
comminuted intra-articular fractures of the proximal humerus involving the posterior aspect of the head, 
surgical neck, and the lesser and greater tuberosity of the left humerus. Surgical management for the noted 
fractures are supported by medical literature to be medically necessary. A delay of care could result in a 
probable further decline of function, along with a risk of neurovascular compromise and overall morbidity. 
Therefore, it would not have been medically reasonable to delay the services until when you returned to the 
service area. Therefore, the records do indicate that the care provided was medically 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 these services have been met. Therefore, we decided that the Plan has to issue 
reimbursement for the outpatient surgery and physical therapy provided out of the country from February 26, 
2023, through May 3, 2023.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the x-ray services provided on January 20, 
2023. 
 
You asked the Plan to waive the deductible for the x-ray services. You say that you were in skilled nursing 
facility and the provider was out-of-network. 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. Your 
contract with the Plan says that there is a $1,000 deductible which applies to out-of-network outpatient 
diagnostic tests and therapeutic services. Your contract with the Plan also says that you must pay a $40 
copayment after meeting the deductible for out-of-network x-rays. 
 
 You have been asked to pay $281.21 towards the deductible. The item or service you asked the Plan to waive 
the deductible for falls within the outpatient diagnostic tests and therapeutic services benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies 
to out-of-network outpatient diagnostic tests and therapeutic services. This cost sharing is a contractual 
obligation that had not been met at the time the x-ray services was received on January 20, 2023. Therefore, we 
decided that the Plan does not have to waive the deductible for the x-ray services provided on January 20, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75774 billed for date of service March 23, 
2023.   
You asked the Plan to pay for procedure code 75774. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 75774 is 7. The MAI value for this code is 3. You billed 10 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 75774 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 75774 billed for date of service March 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514). 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the enrollee does not meet evidence-based criteria. 
 
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 percutaneous vertebral augmentation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that there is no trial and failure of fracture bracing. More conservative 
measures are 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 percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 21, 
2023, to June 17, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. 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 date of service May 21, 2023, to June 17, 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 would benefit from an IRF admission. 
The Plan denied your request. The Plan says based on the available information, admission to an IRF 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 review of the record has determined the enrollee does not require an IRF 
admission with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. There is not a reasonable expectation that this enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 6, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed services are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 7, 2023. 
 
You asked the Plan to pay for OIVIT services. The Plan denied your request. The Plan says the billed services 
are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87899 and 87900) provided May 26, 
2022. 
 
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 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 87899 is infectious agent antigen detection by 
immunoassay with direct optical (ie, visual) observation; not otherwise specified. The definition of code 87900 
is infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics. 
 
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 laboratory services. Our reviewer found for code 87899, 
the documentation submitted was reviewed and does not meet criteria. Laboratory report does not include 
sufficient documentation to confirm, infectious agent antigen detection by immunoassay with direct optical (ie, 
visual) observation; not otherwise specified, was performed. For CPT 87899, The lab analyst performs the 
technical lab test to analyze for an infectious agent by immunoassay with direct optical, meaning visual, 
observation; use this code for those infectious organisms not specifically identified by another analysis code. 
This procedure was not found in medical record, and therefore, cannot be verified. 
 
For code 87900, the documentation submitted was reviewed and does not meet criteria. Laboratory report does 
not include sufficient documentation to confirm, infectious agent drug susceptibility phenotype prediction 
using regularly updated genotypic bioinformatics. For CPT 87900, The lab analyst measures a patient's 
susceptibility or resistance to drugs aimed at a virus. The test predicts the behavior of the phenotype based on 
comparing patient data to regularly updated genotypic bioinformatics. The clinician can use the information to 
help in deciding which drugs to prescribe. This procedure was not found in medical record, and therefore, 
cannot be verified. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87899 and 87900) provided May 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays of the mandible, teeth, spine, and neck provided 
on March 3, 2023, billed with codes 70100, 72040, 70310 and 74230. 
 
You asked the Plan to pay for the x-rays. You say that medical records submitted support codes 70100, 72040, 
70310, 74230 and should be paid. The Plan denied your request. The Plan says that POS 11 (office setting) was 
billed, however, documentation received does not support that the services were performed in an office or other 
outpatient setting but rather in a mobile setting at a skilled nursing facility. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, 
they are often provided to serve an entity for which another POS code exists. For example, a mobile unit may 
be sent to a physician's office or a skilled nursing facility. If the mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity. However, if the mobile unit 
is not serving an entity which could be described by an existing POS code, the providers are to use the Mobile 
Unit POS code 15.  
 
We looked at the file and Medicare rules. The records show that the enrollee received mobile radiology 
services at a nursing home. The POS code listed on the claim is for an office POS. There is no evidence these 
services were provided in the office setting. Therefore, we decided that the Plan does not have to pay for the x-
rays of the mandible, teeth, spine, and neck provided on March 3, 2023, billed with codes 70100, 72040, 70310 
and 74230.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 3, 2023. 
 
You asked the Plan to pay for the office visit. You say that outpatient mental health is covered for individual 
visits and the on-line documentation does not reflect a difference between in-network or out-of-network. The 
Plan denied your request. The Plan says the services obtained by the member were rendered by a provider who 
does not accept Medicare assignment. The provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on May 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for five units of procedure code 87481 billed for date of service 
November 15, 2022. 
 
You asked the Plan to pay for five units of procedure code 87481. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says this code is not supported 
in the medical record for the number of units billed. Only four units are 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 87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe 
technique. 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 five units of procedure code 87481. Our reviewer says that 
this code is not supported in the medical record. Our reviewer found the sample in this case was a urine sample. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of five units of procedure code 87481 have not been met. Therefore, we decided 
that the Plan does not have to pay for five units of procedure code 87481 billed for date of service November 
15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80048 and 82040 billed for date of service 
March 17, 2023.  
 
You asked the Plan to pay for procedure codes 80048 and 82040. You say that you disagree with the denial. 
The Plan denied your request. The Plan says payment for codes 80048 and 82040 is bundled into payment for 
code 80053. 
 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 80048 
is a column II code to column I code 80053 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Code 82040 is a column II 
code to column I code 80053 with a modifier indicator of 1. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 80048 and 82040 billed for date 
of service March 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport rendered on April 26, 2023. 
 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 12, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the ambulance transport rendered on April 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on April 05, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are reconsideration request indicating that the 
services were provided pursuant to a physician order. 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 lab testing provided on 
April 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99204-
25) rendered on June 28, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter." 
 
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 the documentation does not 
support CPT 99204 as a significant, separately identifiable evaluation and management service from CPT 
31238. 
 
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 evaluation and management services (procedure code 99204-25) rendered on June 28, 2023.