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

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 24, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 30, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the respiratory assist device, bi-level pressure capability, 
with back-up rate feature (E0471) provided October 21, 2022. 
 
You asked the Plan to pay for  the respiratory assist device. You say that the enrollee was supplied with the 
items to treat symptoms of obstructive sleep apnea and daytime drowsiness You have attached all supporting 
medical records.  The Plan denied your request. The Plan says per NCD guidelines, the primary diagnosis code 
G47.33 on the claim line does not meet medical necessity for procedure code E0471. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file and Medicare rules. The records show that the claim was billed with a primary diagnosis 
code G47.33 - obstructive sleep apnea. Based on this information, we decided that Medicare rules for coverage 
of the respiratory assist device have not been met. Therefore, we decided that the Plan does not have to pay for  
the respiratory assist device, bi-level pressure capability, with back-up rate feature (E0471) provided October 
21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on April 11, 2022. 
 
You asked the Plan to pay for imaging services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does 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 31635 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with removal of foreign body. 
 
In this case, the CPT Code Manual definition of code 31625 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites. 
 In this case, the CPT Code Manual definition of code 31645 bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial. 
 
In this case, the CPT Code Manual definition of code 31624 bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with bronchial alveolar lavage. 
 
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 imaging services. Our reviewer says that procedure codes 
31635, 31625, 31645, and 31624 are not supported by the medical record. Our reviewer found the medical 
record does not include a procedure report for bronchoscopy service, and therefore cannot be 
verified.  Documentation includes a pathology report and evaluation and management service. Was unable to 
cite report, as this procedure was not found in medical record submitted for review. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of imaging services have not been met. Therefore, we decided that the Plan does 
not have to pay for imaging services provided on April 11, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the requested Evenity is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Forteo first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Forteo. The documentation does not support that Forteo would likely be 
less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services rendered on November 23, 2021. 
 
You asked the Plan to pay for the services. You say that other insurance was originally billed. The Plan denied 
your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until January 18, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for emergency room services rendered on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat diagnostic medial branch block injections 
(64493, 64494). 
 
You asked the Plan to pre-approve the injections. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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 the injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the records show the enrollee had a previous effective treatment with radiofrequency ablation. 
The enrollee meets coverage criteria for a repeat radiofrequency ablation procedure. The requested injections 
are not 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat diagnostic medial branch block injections (64493, 64494).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for 
admission to an IRF.  
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay 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. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 25, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) rendered on 
September 1, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there are no concerning symptoms or signs of misuse in the record. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the reviewed documentation indicates that the enrollee has chronic pain. There are no concerning 
symptoms or signs of misuse noted in the record. The large panel of tests ordered are rarely needed in an 
outpatient or office setting. This type of panel testing to see how much exactly of each drug is in the system is 
not needed to help guide care. The review has determined that the enrollee did not need 22+ drug classes tested 
in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (procedure code G0483) rendered on September 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 1, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay $104.99 more for the progressive lenses (V2781) and polycarbonate lenses 
(V2784) provided on December 7, 2022. 
 
You asked the Plan to pay more for the progressive lenses and polycarbonate lenses. You say that you do not 
understand why the total amount paid by the Plan was $195.01 instead of $300 which is the amount approved 
by the Plan. The Plan denied your request. The Plan says that the individual maximum charges limit has been 
reached. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $300 every calendar year for supplemental eye wear. 
 
We looked at the file and the Plan's rules. The provided documentation shows that the amount for the eyewear 
that was allowed by the Plan was $300, but only $195.01 was paid by the Plan. There is no documentation 
provided showing your $300 allowance has been exhausted. Based on this information, we decided that the 
Plan's rules for coverage of the progressive lenses and polycarbonate lenses have been met. Therefore, we 
decided that the Plan has to pay $104.99 more for the progressive lenses (V2781) and polycarbonate lenses 
(V2784) provided on December 7, 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: ER
Decision: Favorable

 
We decided that the Plan has to pay for physician's services for an emergency department visit provided on 
September 9, 2022. 
 
You asked the Plan to pay for physician's services for an emergency department visit. You say that you have 
provided proof of enrollment from CMS for this provider. The Plan denied your request. The Plan says that this 
provider has been precluded from participation in Medicare at the time services were rendered.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided documentation showing that this 
physician (NPI 1285083519) and/or the billing group (NPI 1861430555) have been precluded from 
participation in Medicare at the time services were rendered. Therefore, we decided that the Plan has to pay for 
physician's services for an emergency department visit provided on September 9, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87631 and 99702 billed for date of service September 
29, 2022. 
 
You asked the Plan to pay for codes 87631 and 99702. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says for code 87631, the claim for this molecular 
pathology testing did not include the required unique identifier. Code 99702 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported for code 87631.  
 
In addition, Medicare rules state that the Physician Fee Schedule Status Indicator B means that payment for 
covered services is always bundled into payment for other services not specified. There will be no payment 
amounts for these codes and no separate payment is ever made. We find that procedure code 99072 has a status 
indicator of B on the Physician Fee Schedule. This means that procedure code 99072 is not separately payable. 
 
Based on this information, we decided that Medicare rules for coverage of codes 87631 and 99702 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 87631 and 99702 billed for date 
of service September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 28, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service November 3, 
2022.  
 You asked the Plan to pay for procedure code 99291. You say that the enrollee had multiple exams on this date 
of service. You are requesting reconsideration for payment on this claim. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 99291 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed for date of 
service November 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78290-26 billed for date of service December 
20, 2022.  
 
You asked the Plan to pay for procedure code 78290-26. You say that the claim was billed correctly and should 
be paid. 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 78290-26 is 1. The MAI value for this code is 3. You billed 2 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 78290-26 have not been met.  Therefore, we decided that 
the Plan does not have to pay for procedure code 78290-26 billed for date of service December 20, 2022.