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

 
We decided that the Plan does not have to pay for procedure codes 20936 and 20930 billed for date of service 
September 11, 2023. 
 
You asked the Plan to pay for procedure codes 20936 and 20930. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure codes 20936 and 20930 are 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 codes 20936 and 20930 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20936 and 20930 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20936 and 20930 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20936 and 20930 billed for date of service 
September 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 64483 billed for date of service 
June 12, 2023.  
 
You asked the Plan to pay for two units of procedure code 64483. You say that you are requesting the claim be 
reviewed and reprocessed for payment. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64483 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of two units 
of procedure code 64483 have not been met. Therefore, we decided that the Plan does not have to pay for two 
units of procedure code 64483 billed for date of service June 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 0089U and 81345 for date of service June 
29, 2023. 
 
You asked the Plan to pay for procedure codes 0089U and 81345. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says code 0089U does not meet criteria. Code 81345 is bundled 
with code 0089U and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that PLA is covered when the lesion must meet one 
or more ABCDE criteria (Asymmetry, Border, Color, Diameter, Evolving). 
Review of the file shows that the medical records do not document the size of the lesion or that it meets 
ABCDE criteria. This means the PLA is not covered. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 0089U and 81345 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 0089U and 81345 for date of service June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 13, 2023. 
 
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 coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services provided on March 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for outpatient surgery provided on August 08, 
2023. 
 
You asked the Plan to reduce the copayment for outpatient surgery. You say that you had this procedure done 
before on the other foot and it wasnt as much. 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 $175 
copayment for outpatient hospital services. 
 
You have been asked to pay a $175 copayment for outpatient surgery. This item/service falls within the 
outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for outpatient 
surgery provided on August 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ostomy supplies to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the ostomy supplies. You say that you are requesting reconsideration of the 
denied items. The Plan denied your request. The Plan says the items were not approved. 
 
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 items at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve the ostomy 
supplies to be provided by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatry services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve psychiatry services. You say that you want a provider that specializes in 
your specific issue, as well as using behavioral health techniques. The Plan denied your request. The Plan says 
there are other providers available who are in-network, who are within the Medicare allowable distance from 
your residence. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from your home who can provide psychiatry services.  Under Medicare rules, this means that contract providers are accessible to you. Therefore, we decided that the 
Plan does not have to pre-approve psychiatry services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you need the raised toilet seat because the 
one you have is broken. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for the enrollee, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 3, 2023, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81334, and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 3, 2023, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81334, and 81351.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the hot tub provided on June 28, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to reimburse for the hot tub. You say that the hot tub treatment is helping with your 
condition.  The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be 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 reimburse for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to reimburse for these items/services. 
Therefore, we decided that the Plan does not have to reimburse for the hot tub provided on June 28, 2023, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service May 5, 2023.  
 
You asked the Plan to pay for procedure code 88377. You say that please reconsider your claim and apply in-
network benefits for the services rendered by your lab. 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 88377 is 5. The MAI value for this code is 3. You billed 6 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 88377 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88377 billed for date of service May 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric hospital services provided from  
June 12, 2023, to June 16, 2023.  
 You asked the Plan to pay for the inpatient psychiatric hospital services. You say that the inpatient psychiatric 
hospital services were medically necessary. The Plan denied your request. The Plan says the inpatient 
psychiatric hospital services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that the requested inpatient psychiatric hospital services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that based upon review the records 
provided it was not expected this enrollee would improve in a reasonable period of time as he did not have 
dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any 
behavioral issues. The enrollee was not showing any withdrawals. It did not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
as he did not have dangerousness to self or others, perceptual disturbance including delusions, auditory or 
visual hallucinations. Based upon review the records provided for the admission of this enrollee does not meet 
criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to himself or 
others, no auditory or visual hallucinations. He is noted to be cooperative and compliant with treatment while 
not showing any aggressive behaviors as the patient was not showing any withdrawals. 
 
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 inpatient psychiatric hospital services have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient psychiatric hospital services provided from  
June 12, 2023, to June 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric scooter. 
 
You asked the Plan to pre-approve the electric scooter. You say that you have a bad knee and hip. You say that 
an electronic scooter would help you get around better. You say that you use a walker in the house but cannot 
get it into your car. You also say that you cannot use a wheelchair because you cannot push yourself. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an electric scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery. 
 
You asked the Plan to pre-approve these services. You say that you have problems with your electricity and 
need a backup. The Plan denied your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a backup battery.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 18, 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 Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on August 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 28, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says 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 the laboratory services 
provided on June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
July 26, 2023. 
 
You asked the Plan to pay for the CGM supplies. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the enrollee did not meet criteria for the items rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not had an in-
person visit with their treating physician to evaluate their diabetes control and to determine whether the criteria 
for coverage have been met.  Based on this information, we decided that Medicare rules for coverage of the 
CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor (CGM) supplies provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77012 and 99153 billed for date of service 
February 15, 2023.  
 
You asked the Plan to pay for procedure codes 77012 and 99153. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
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. Medicare rules also say that providers must report services correctly. Providers must report services with 
the appropriate CPT code. 
 
In this case, the MUE for CPT code 77012 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. Additionally, the review shows that the 
medical records provided represent professional charges; however, procedure code 99153 was provided in a 
facility with a place of service code of 21. Procedure code 99153 has a PC/TC Modifier Status of 3, which 
specifies a Technical Component only code. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 77012 and 99153 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 77012 and 99153 billed for date of service February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99233 performed on date of service June 30, 2022.  
 
You asked the Plan to pay for 99233. You say that 99233 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99233 is denied because it is not supported in the 
provided documentation. 
 
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. In this case, we have confirmed that the provided medical records do 
not include any supporting documentation or an evaluation and management note for date of service in 
question, June 30, 2022. Based on this information, we decided that there is insufficient information in the 
record to determine if Medicare rules for coverage of 99233 have been met. Therefore, we decided that the Plan 
does not have to pay for the evaluation and management services described by code 99233 performed on date 
of service June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on July 21, 2023, by an out-of-
network (OON) provider.  
 
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 the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home visit provided on July 21, 2023, by an 
out-of-network (OON) provider.