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

 
We decided that the Plan does not have to pay for physicians services provided on January 20, 2023. 
 
You asked the Plan to pay for the physicians services. You say that you were never notified that this provider 
was no longer in-network. The Plan denied your request. The Plan says the provider is not in our network and 
the services were received within the Plans service area. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for physicians services provided on January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0675 for dates of service June 15, 2022, to July 12, 2022. 
 
You asked the Plan to pay for the PCD. You say that this item was medically necessary for the patient. The 
Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that PCDs coded as E0675 will be denied as not 
reasonable and necessary. You billed the PCD in question with code E0675, so this is a non-covered item, 
regardless of appropriateness. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PCD have not been met. Therefore, we decided that the Plan does not have to pay for the 
pneumatic compression device (PCD) billed with code E0675 for dates of service June 15, 2022, to July 12, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and is 
approved by Medicare. 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 August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 12, 2022, billed with 
codes 81201, 81272, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81345, & 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. 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 
October 12, 2022, billed with codes 81201, 81272, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 
81345, & 81351.
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 99283 and 73110. We decided that the Plan does not 
have to pay for procedure codes A6216 and A4554 
 
You asked the Plan to pay for procedure codes 99283, 73110, A6216, and A4554 billed for February 14, 2023.. 
You say that you disagree with the denial. The Plan says that payment is not allowed for these services because 
it is not appropriate for the CPT codes billed. 
 
We decided that the Plan has to pay for procedure codes 99283 and 73110. 
 
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. The Plan states that codes 99283 and 73110 are not allowed because they are 
inappropriate for the CPT codes billed. The Plan has not provided any documentation to support that these 
codes are not payable as billed. Therefore, we decided that the Plan has to pay for procedure codes 99283 and 
73110 billed for February 14, 2023. 
 
We also decided that the Plan does not have to pay for procedure codes A6216 and A4554. 
 
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 A6216 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A6216 is not separately payable. Procedure code A4554 has a status indicator of N on the 
Physician Fee Schedule. This means that code A4554 is non-covered. Therefore, we decided that the Plan does 
not have to pay for procedure codes A6216 and A4554 billed for February 14, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth mental health services provided by a Licensed 
Mental Health Counselor (LMHC) from January 26, 2022, to February 9, 2023. 
 
You asked the Plan to pay for the LMHC services. You say that you did not know that you could no longer see 
an out-of-network mental health counselor. You said that you have been seeing this provider for years and you 
are comfortably with them. The Plan denied your request. The Plan says services with a LMHC are not 
covered.  The Plan also says that telehealth mental health services are not covered with out-of-network 
providers. 
 
The Plan must follow Medicare rules. Medicare rules say that that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists.  
 
In this case, the provider you saw is a LMHC.  This is not a valid provider type for Medicare.  In addition, your 
Plan contract explicitly states that out-of-network coverage is not available for mental health services delivered 
via telehealth. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LMHC services have not been met. Therefore, we decided that the Plan does not have to pay 
for telehealth mental health services provided by a Licensed Mental Health Counselor (LMHC) from January 
26, 2022, to February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99356, 99357) provided on December 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (99356, 99357) is included in the 
global surgery payment for the procedure (21210) provided on the same date of service. 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 the services (99356, 99357) provided on December 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 24, 2022, to 
May 28, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the diagnoses billed. The Plan denied your request. The Plan says there is not 
sufficient documentation to clinically validate the diagnosis of A41.9 (Sepsis unspecified organism). As a 
result, a lower DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis of A41.9 (Sepsis unspecified organism). 
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 hospital services at the DRG 
originally billed. Our reviewer says that the diagnosis of A41.9 (Sepsis unspecified organism) is not supported 
in the medical record. Our physician reviewer found the patient is a 78-year-old male with chronic obstructive 
pulmonary disease on home oxygen and heart failure who presented to the hospital with shortness of breath. 
His workup revealed congestive heart failure and pneumonia which was treated with diuresis and antibiotics. 
He revealed he had stopped his Lasix at home due to the urinary frequency. The patient required oxygen 
support, however, creatinine, platelets, bilirubin were stable/normal, he was alert and oriented and had no 
reported oliguria. Sepsis 3 criteria was not met. The patient did not have sufficient evidence of a systemic 
dysregulated response to infection leading to significant organ failure that is life-threatening to support the 
diagnosis code, A41.9 (sepsis).   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 24, 2022, to May 28, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent drug susceptibility phenotype prediction 
using regularly updated genotypic bioinformatics (87900) provided on October 17, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says this procedure code is not approved for the diagnosis billed (R30.0: Dysuria). 
 
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the case file does not contain clinical documentation supporting that the infectious agent drug 
susceptibility phenotype prediction using regularly updated genotypic bioinformatics (87900) provided on 
October 17, 2022, was medically reasonable and necessary 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pay for the infectious agent drug susceptibility phenotype prediction using regularly updated genotypic 
bioinformatics (87900) provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the nerve service (95941) provided on November 1, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says that it is past the 1-year mark and the corrected claim has still not been received. 
 
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. The appealed claim processed correctly as this service has already been paid 
under another claim. The claim that paid needed a corrected claim to be submitted for code 95941. The 
corrected claim has not been received; however, the Plan denied this because they state the provider was past 
the 1-year mark and that is not true. The provider had until November 1, 2023, to submit the correct claim. 
Therefore, the Plan's denial is not correct. Please note, the Plan does not have to pay for the duplicate claim 
because they paid for the services on the claim that is being denied as untimely. Therefore, we decided that the 
Plan has to pay for the nerve service (95941) provided on November 1, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radical mastectomy (19305) and related services provided 
on June 2, 2022. 
 
You asked the Plan to pay for a radical mastectomy and related services. You say that you have billed the 
service at issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no payment under the OPPS for services 
that Medicare designates to be inpatient-only services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a radical mastectomy and related services have not been met. Specifically, the procedure at issue 
has an OPPS status indicator of "C," indicating an inpatient-only service. The services at issue have been 
reported on an outpatient claim (bill type 131). An inpatient-only service cannot be paid on an outpatient claim. Because the base procedure is not covered, payment for related services is also denied. Therefore, we decided 
that the Plan does not have to pay for a radical mastectomy (19305) and related services provided on June 2, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
January 30, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is not enrolled to be eligible to bill 
Medicare.  
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital.  
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on January 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 16, 2022, to 
February 14, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA is on file with the Plan. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 16, 2022, to 
February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99458 billed for date of service February 22, 
2023.   
You asked the Plan to pay for procedure code 99458. 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 99458 is 3. The MAI value for this code is 3. You billed 4 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 99458 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99458 billed for date of service February 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiography (TTE) (93306) provided 
March 1, 2023. 
 
You asked the Plan to pay for the diagnostic service. You say that you feel that this should be covered because 
your provider was trying to rule out a stroke and if your heart was okay. The Plan denied your request. The 
Plan says Based upon the clinical notes reviewed the enrollee does not meet medical necessity guidelines 
 
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 diagnostic service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in the absence of any supportive clinical evidence of a cardiac abnormality the 
clinical guidelines do not support carrying out a TTE in this setting. In summary, there is no supportive 
evidence for the medical necessity of a TTE in this this enrollee's clinical management. 
 
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 diagnostic service have not been met. Therefore, we decided that the Plan 
does not have to pay for the transthoracic echocardiography (TTE) (93306) provided March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service December 
16, 2022.  
 
You asked the Plan to pay for procedure code 88341. You say that these services were necessary and are 
supported in the medical record. 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 88341 is 13. The MAI value for this code is 3. You billed 16 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.  
 
You asked the Plan to pre-approve a lumbar epidural steroid injection. You say that a lumbar epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the requested lumbar epidural 
steroid injection does not meet the Medicare LCD coverage criteria.  
 The Plan follows Medicare rules. Medicare rules say that an epidural steroid injection is covered when the 
criteria listed in the Medicare rules section of this decision are met.  
 
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 a lumbar epidural steroid injection. Our 
reviewer says that the requested lumbar epidural steroid injection is not considered medically necessary in this 
case. Our physician reviewer found that the Medicare LCD criteria is at least 50% pain improvement for three 
months. This has not been met. Therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lumbar epidural steroid injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar epidural steroid injection.