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

 
We decided that the Plan does not have to pay for the laboratory services coded as 36415, 84443, 85025, 
80053,83036, provided on June28, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of this claim for 
payment. The Plan denied your request. The Plan says enrollees must receive their medical services from an 
in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 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 laboratory services coded as 36415, 84443, 
85025, 80053,83036, provided on June28, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 28, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services rendered on April 10, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed with the correct place of service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 02; however, 
the file shows that code Q3014 can only be billed with POS code 11. Therefore, we decided that the Plan does 
not have to pay for the telehealth services rendered on April 10, 2023.
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 
June 26, 2023.  
 
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 June 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service June 21, 
2023. 
 You asked the Plan to pay for procedure code 71045. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 71045 is bundled into payment for code 71046. 
 
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 71045 
is a column II code to column I code 71046. 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 71045 billed for date of service June 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chest x-ray with a tertiary level of care provider. 
 
You asked the Plan to pre-approve a chest x-ray with a tertiary level of care provider. You say that the enrollee 
will experience a lot of stress and anxiety because he does not work well with new service locations. The Plan 
denied your request. The Plan says the requested chest x-ray with a tertiary level of care provider is not 
medically necessary.  
 
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 a chest x-ray with a tertiary level of 
care provider. Our reviewer says that the requested chest x-ray with a tertiary level of care provider is not 
considered medically reasonable and necessary in this case. Our physician reviewer found that the record 
indicates that the enrollee has testicular cancer.  The record is insufficient to support the safety and efficacy, as defined by Medicare rules, of the requested service. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are not satisfied.   
 
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 chest x-ray with a tertiary level of care provider have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a chest x-ray with a tertiary level of care provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73120 billed for date of service June 21, 
2023. 
 You asked the Plan to pay for procedure code 73120. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 73120 is bundled into payment for code 73130. 
 
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 73120 
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. Therefore, we 
decided that the Plan does not have to pay for procedure code 73120 billed for date of service June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA testing (81479) provided on April 4, 2023. 
 
You asked the Plan to pay for PrismRA testing. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of PrismRA testing have not been met. Therefore, we decided that the Plan does 
not have to pay for PrismRA testing (81479) provided on April 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis (L1686) and hip abduction flexion extension 
control (L2624) provided June 30, 2023. 
 You asked the Plan to pay for the orthoses. You say that you are requesting reconsideration and have attached 
the supporting documentation. Please reprocess the claim. The Plan denied your request. The Plan says the 
documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain valid relevant medical records which support medical necessity for the supplies 
provided in this case. Specifically, the records do not show that the enrollee has had an appropriate face-to-face 
encounter documented in the records to substantiate the need for these items. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the hip orthosis (L1686) and hip abduction flexion extension control (L2624) 
provided June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the enteral feeding supply kit provided from May 8, 2023, to June 4, 
2023. 
 
You asked the Plan to pay for the enteral feeding supply kit. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the place of service billed is not an appropriate place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage consideration for DMEPOS items in a 
Skilled Nursing Facility (31), unless the beneficiary is in a covered Part A stay, or a Nursing Facility (32) is 
limited to parenteral/enteral nutrition.  
 
We looked at the file and Medicare rules. The items at issue are enteral nutrition supplies. These supplies were 
billed with a place of service of 32 (nursing facility). Medicare rules state that there is coverage consideration 
for enteral nutrition in a nursing facility (place of service 32). Based on this information, we decided that 
Medicare rules for coverage of the enteral feeding supply kit have been met. Therefore, we decided that the 
Plan has to pay for the enteral feeding supply kit provided from May 8, 2023, to June 4, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab J0897). 
 You asked the Plan to pre-approve Prolia. You say that the request is medically necessary. The Plan denied 
your request. The Plan says step therapy requirements have not been met.  
 
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 Prolia. Our reviewer says that the 
criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of an 
intravenous bisphosphonate (zoledronic acid) for at least 12 months before they will approve the requested 
drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided 
indicating that the Plan's required drug would likely be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (denosumab J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99053 and 99283 provided on June 1, 2023. 
 
You asked the Plan to pay for procedure code 99053 and 99283. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the billed codes are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79. The rules say that the Physician Fee Schedule Status 
Indicator B means that payment for covered services is always bundled into payment for other services not 
specified. 
 
We looked at the file and Medicare rules. Code 99283 is within the global surgery period of code 30901 
provided on June 1, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. Code 99053 has a status indicator of "B" and is 
not separately payable. As such, the billing rules for these services have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99053 and 99283 provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 96413, defined as chemotherapy administration, 
intravenous infusion technique; up to 1 hour, single or initial substance/drug, billed on date of service May 9, 
2023. 
 You asked the Plan to pay for 96413. You say that 96413 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 96413 is denied because it was not billed in 
accordance with coding guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that chemotherapy administration codes are listed as 
96401-96549 and apply to parenteral administration of non-radionuclide anti-neoplastic drugs, anti-neoplastic 
agents provided for treatment of noncancer diagnoses, or to substances such as certain monoclonal antibody 
agents, and other biologic response modifiers. The rules also say that J1602 should be billed with 
chemotherapy administration codes. 
 
We looked at the file and Medicare rules. In this case, we confirmed that 96413 is a chemotherapy 
administration code and was billed with code J1602, defined as injection, golimumab, 1 milligram, for 
intravenous use. Per LCA A59073, J1602 is not to be used with chemotherapy administration codes and should 
instead be billed using the appropriate intravenous injection/infusion code. Based on this information, we 
decided that Medicare rules for coverage of 96413 have not been met. Therefore, we decided that the Plan does 
not have to pay for code 96413, defined as chemotherapy administration, intravenous infusion technique; up to 
1 hour, single or initial substance/drug, billed on date of service May 9, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99284) 
provided on June 28, 2023. 
 
You asked the Plan to pay for emergency department services. You say that the CPT 99284 is more appropriate 
based on the level of services required. The Plan denied your request. The Plan says the CPT 99283 is more 
appropriate for the services rendered. 
 
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 a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
 
  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 emergency department services. Our reviewer says that the 
records do not support the services at issue in this case. Our reviewer found that the documentation contains a 
brief history and expanded physical examination. The enrollee was without complaint and found to be 
clinically stable. Labs were checked out of an abundance of caution, but the medical decision making appears 
to be of low complexity. Therefore, the documentation submitted does not support that the provider performed 
a moderate level of medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of emergency department services have not been met. Therefore, we decided that 
the Plan does not have to pay for emergency department services (procedure code 99284) provided on June 28, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to require additional acute care services that can safely be 
provided at the current facility until more stable and appropriate for transfer. The enrollee does not require 
services at the LTACH level that are not already available at the current facility. Transfer to an LTACH is not 
medically necessary and would not be clinically advantageous.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thyroid uptake measurement (78012). 
 
You asked the Plan to pre-approve a thyroid uptake measurement. The Plan denied your request. The Plan says 
the requested service is not covered by Medicare or the health plan. 
 
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 a thyroid uptake measurement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided records did not clearly show recent abnormal thyroid hormone 
levels, recent thyroid imaging (ultrasound), or unclear fine needle aspiration results to help justify this second-
line testing method. Our reviewer found that therefore, this request for thyroid uptake measurement (78012) 
will be considered not medically necessary based on the provided documentation.   
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 thyroid uptake measurement have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a thyroid uptake measurement (78012).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular artery embolization procedure (36246, 
36247). 
 
You asked the Plan to pre-approve the genicular artery embolization procedure. You say that this procedure is 
medically necessary for the treatment of the enrollee's condition and will provide a long-lasting pain relief that 
will improve the enrollee's quality of life. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 genicular artery embolization 
procedure. Our reviewer says that the requested service is not considered medically reasonable and necessary 
in this case. Our physician reviewer found this procedure is considered an experimental/investigational 
procedure. 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 the genicular artery embolization procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the genicular artery embolization procedure (36246, 36247).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service June 21, 
2023. 
 You asked the Plan to pay for procedure code 76775. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 76775 is bundled into payment for code 93975. 
 
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 76775 
is a column II code to column I code 93975. 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 76775 billed for date of service June 21, 2023.