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

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
(83789-59) provided June 3, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 83789 is a column II code to column I code G0480; however, 83789 
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 laboratory services. Our reviewer found there is no 
documentation that CPT code 83789 was distinct from Healthcare Common Procedure Coding System 
(HCPCS) code G0480 which was billed and paid. Provided records in this case document one urine specimen 
was obtained and tested at one point in time on June 3, 2023, with no evidence the procedures were distinct or 
separate.  
 
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 mass spectrometry and tandem mass spectrometry (83789-59) provided June 3, 
2023.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (87400 and 87637) provided August 
16, 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 87637 is infectious agent detection by nucleic acid (DNA 
or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), 
influenza virus types A and B, and respiratory syncytial virus, multiplex 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 the laboratory services. Our reviewer found the 
documentation submitted was reviewed and does not meet criteria. CPT 87637 represents multiple procedures; 
however, the physician order documents "full respiratory panel + Covid". The documentation does not include 
what tests to perform. Therefore, this procedure code cannot be verified. Furthermore, 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 87400 is a column II code to column I code 87637. 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. 
 
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 (87400 and 87637) provided August 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76775) provided on January 17, 
2023. 
 
You asked the Plan to pay for the ultrasound. You say that you want to appeal this bill. The Plan denied your 
request. The Plan says the ultrasound was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the ultrasound have been met. The 
record shows that the Plan made three separate requested for medical records, but none were received. Without medical records to review, it cannot be determined that the service at issue in this case should be paid.. 
Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound (76775) provided on 
January 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service April 17, 
2023. 
 
You asked the Plan to pay for procedure code S2900. You say that this should be paid for. 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 S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service September 
14, 2022. 
 
You asked the Plan to pay for procedure code 81345. You say that this testing was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says payment for code 81345 is bundled into 
payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 code 81345 billed for date of service September 14, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service October 25, 
2022. 
 You asked the Plan to pay for procedure code 87798. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87798 is bundled into payment for code 87801. 
 
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 87798 
is a column II code to column I code 87801. 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 code 87798 billed for date of service October 25, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven (7) home health skilled nursing visits (G0299). You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration due 
to medical necessity. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation does not specify any new medical concerns, changes in medications or plan of care 
(documented concerns are functional in nature) thus the records do not show that 7 home health skilled nursing 
visits are required to effectively provide treatment, care, and/or services in order to improve the enrollee's 
condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seven (7) home health skilled nursing visits (G0299).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prescription drug, oral, non-chemotherapeutic, 
Myrbetriq 25 mg tablets (J8499). 
 
You asked the Plan to pre-approve the medication. You say that you are appealing for a tier exception for this 
medication due to cost. 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 prescription drug, oral, 
non-chemotherapeutic, Myrbetriq 25 mg tablets (J8499).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes Q0092 and R0070 rendered on April 4, 
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 denied codes remain 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 the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) Q0092: 
 
Set-up portable x-ray equipment 
 HCPCS R0070: 
 
Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or 
location, one patient seen 
 
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 insufficient 
documentation of a left should x-ray series on April 4, 2023 to support the billed codes. There is no 
documentation of the portable nature of the series, and set-up of the equipment. 
 
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 Q0092 and R0070 rendered on April 4, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from June 1, 2023, to  
June 29, 2023. 
 
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this provider type is not eligible to participate in the Medicare 
program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from 
June 1, 2023, to June 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the inpatient substance abuse facility services 
provided from October 28, 2022, to November 9, 2022. 
 
You asked the Plan to reimburse you for the inpatient substance abuse facility services. You say that at the time 
the services were initiated, you believed that your life was in peril and that without immediate medical 
attention the result would be your death. You say that your circumstances meet all the criteria for an emergency 
and for emergency care as defined in the Plans document. The Plan denied your request. The Plan says the 
facility is not a Medicare provider or Medicare certified. 
 
The Plan must follow Medicare rules. Medicare rules say that a Substance Abuse Facility is not eligible to 
participate in the Medicare program. 
 
 
 We looked at the file and Medicare rules. The file shows that the provider at issue in this case is a Substance 
Abuse Facility. Medicare says that a Substance Abuse Facility is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the inpatient substance abuse 
facility services provided from October 28, 2022, to November 9, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on December 29, 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 is no clinical information supporting the key components of the code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate 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) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function." 
 
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 records do not support any 
history and physical exam, any medical decision making or any presenting problems of any complexity. There 
is no documentation of anything other than a diagnosis. 
 
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 emergency room services (procedure code 99284) rendered on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custodial care services. 
 
You asked the Plan to pre-approve custodial care services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the enrollee's Health Plan does not cover this service. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
custodial care services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73140 and 99214 rendered on April 25, 
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 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 the denied codes is: 
 
CPT 73140: 
 
Radiologic examination, finger(s), minimum of 2 views 
 
CPT 99214: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. When using 
time for code selection, 30-39 minutes of total time is spent on the date of the encounter 
 
In this case, we have confirmed that code 73140 is a column II code to column I code 73130. 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. 
 
We additionally 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 for CPT 99214. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that the enrollee had bike 
riding accident and injury and presented for evaluation of body contusion. The documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level or that 30-39 
minutes were spent. 
 
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 code 73140 and 99214 rendered on April 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from April 20, 2023, to 
April 21, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary due to 
chest pain. The Plan denied your request. The Plan says observation level of care was more appropriate. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee had intermittent chest pain for a few weeks, and was asymptomatic 
in the emergency room. Based on presentation, the documentation does not support that an inpatient stay with 
anticipated more than 2 midnight stay was 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services rendered from April 20, 2023, to April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve a facet joint injection to be provided by an out-of-network provider. You 
say that the Plan approved two procedures with this provider in the past. The Plan denied your request. The 
Plan says that the requested provider is out-of-network and is not contracted with the Plan. There are 
other in-network providers available. The expectation is that members exhaust in-network providers resources 
before seeking out-of-network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a facet 
joint injection to be provided by an out-of-network provider.