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

 
We decided that the Plan does not have to pay for an office visit (procedure code 99214) rendered on 
November 23, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99214-95 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee was treated in a 
telemedicine visit that was rendered on November 23, 2022. The documentation described the enrollee being 
seen for a checkup related to opioid use disorder. A limited visual examination via video was performed. The 
plan was to continue Suboxone. The provided records did not include an appropriate history or examination, 
did not support a moderate level of decision making, nor was there documented evidence of the visit lasting 30-
39 minutes. Therefore the 99214 code was not sufficiently supported.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an office visit (procedure code 99214) rendered on November 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for AVISE CTD autoimmune testing (0312U) provided on 
September 20, 2022. 
 You asked the Plan to pay for AVISE CTD autoimmune testing. You say that this test was medically necessary 
and appropriate. The Plan denied your request. The Plan says there are no medical records from the referring 
physician to support that this test was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of AVISE CTD autoimmune testing have 
been met. Specifically, the limited records provided do not contain any medical records or physician notes from 
the referring provider to support the medical necessity of these services. Therefore, we decided that the Plan 
does not have to pay for AVISE CTD autoimmune testing (0312U) provided on September 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 1, 2022, to April 
30, 2022. 
 You asked the Plan to pay for the home health services. You say that you initially billed this with a Request for 
Anticipated Payment (RAP) claim.  You did submit the NOA and would like this claim reconsidered. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 31, 2022. The NOA was not received by the Plan until May 12, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from April 1, 2022, to April 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 18, 2022, to 
January 13, 2023. 
 You asked the Plan to pay for the home health services. You say that you have provided the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 19, 2022. The NOA was not received by the Plan until April 11, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from December 18, 2022, to January 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88361 billed for date of service April 14, 
2022.  
 
You asked the Plan to pay for procedure code 88361. 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 88361 is 6. The MAI value for this code is 3. You billed 8 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 88361 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88361 billed for date of service April 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for freestanding emergency department services provided on 
October 13, 2022. 
 
You asked the Plan to pay for emergency care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this provider did not enrollee in Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered items or services, 
a provider must be enrolled in the Medicare program.  
 
We looked at the file and Medicare rules. This provider was not enrolled in Medicare so is not eligible for 
payment. Based on this information, we decided that Medicare rules for coverage of emergency care have not 
been met. Therefore, we decided that the Plan does not have to pay for freestanding emergency department 
services provided on October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospitalist visit (99233) provided on March 8, 2023. 
 
You asked the Plan to pay for hospitalist visit. You say that you are appealing this denial. The Plan denied your 
request. The Plan says this service is included in the global surgery period and an appropriate modifier was not 
included to support separate payment. 
 The Plan must follow Medicare rules. Medicare rules say that evaluation and management services are 
generally not payable when performed on the same day as minor surgical procedure 31624.  
 
We looked at the file and Medicare rules. This evaluation and management service code was billed on the same 
day as the associated minor surgical procedure 31624 and a modifier has not been included to support separate 
payment. Based on this information, we decided that Medicare rules for coverage of hospitalist visit have not 
been met. Therefore, we decided that the Plan does not have to pay for a hospitalist visit (99233) provided on 
March 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for glycosylated hemoglobin testing (83036) provided on 
September 22, 2022. You asked the Plan to pay for glycosylated hemoglobin testing. You say that this service was reasonable and 
necessary. The Plan denied your request. The Plan says this service was provided as a screening and is not 
covered by Medicare when performed only for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, glycosylated hemoglobin testing, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for glycosylated hemoglobin testing (83036) provided on September 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on January 12, 2023. 
 
You asked the Plan to pay for the transportation. The Plan denied your request. The Plan says payment is 
included in the facility payment.  
The Plan must follow Medicare rules. Medicare rules say that payment for ambulance transportation provided 
to inpatient is covered by the prospective payment rate or reimbursed as reasonable costs under Part A to 
hospitals excluded from PPS. 
 
We looked at the file and Medicare rules. Payment for the requested ambulance services is included in the Part 
A inpatient rate. Based on this information, we decided that Medicare rules for coverage of the transportation 
have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation 
provided on January 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 3, 2022, billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401, 
0031U, 0032U, 0033U and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are supported in the medical record. 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 
August 3, 2022, billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 
81328, 81355, 81335, 81401, 0031U, 0032U, 0033U and 81479.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 17, 2023. 
 
You asked the Plan to pay for the medical services. You say that you billed a valid diagnosis for this service. 
The Plan denied your request. The Plan says you billed two diagnosis codes together that should not be billed 
together. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. In this 
case, you billed this claim with diagnoses of D12.3 and K63.5. Code K63.5 is an Excludes1 code under code 
D12.3, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on February 17, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
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. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on February 17, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing provided on November 22, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered test. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory providers who bill molecular 
diagnostic tests must register test services on the DEX Diagnostics Exchange.  
 
We looked at the file and Medicare rules. The PrismRA test in this case is not registered and covered under the 
DEX Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the PrismRA testing 
provided on November 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D testing provided on November 2, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the guidelines state that endoscopy has become standard practice for diagnosis. The National Comprehensive Cancer Network falls short of recommending WATS-3D, stating that the utility and accuracy 
of the WATS-3D biopsy for detecting high grade dysplasia/adenocarcinoma in patients with Barretts 
esophagus needs to be evaluated in larger phase III randomized trials (National Comprehensive Cancer 
Network, 2020). The requested WATS testing at issue in this case was not medically reasonable or 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the WATS 3D testing provided on November 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CTA scan of the heart with 3-demensional (3D) 
imaging. 
 
You asked the Plan to pre-approve the CTA scan of the heart. The Plan denied your request. The Plan says a 
CTA of the heart with 3D imaging is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CTA scan of the heart. Our 
reviewer says that the enrollee does not meet the coverage criteria. Our physician reviewer found that the 
enrollee has a good exercise capacity as they can walk many blocks. While the enrollee's reported chest 
discomfort is not consistent with angina, they are able to walk and complete a standard exercise tolerance test. 
The LCD coverage criteria has not been met because the request is not to evaluate acute chest pain. 
 
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 CTA scan of the heart have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CTA scan of the heart with 3-demensional (3D) imaging.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services billed for date of service January 25, 
2023. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the claim was not submitted with a type of bill suitable for payment. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for the outpatient services billed for date of service January 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 88112, 88313, 88312 
provided August 10, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the services were provided in good faith with 
the expectation of receipt of payment for services provided. It is unreasonable to be penalized for providing 
such a service to the enrollee. The Plan denied your request. The Plan says services were rendered by a 
provider who is not eligible for Medicare. The taxonomy listed on the claim is not eligible to participate in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 88112, 
88313, 88312 provided August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 14, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare shall automatically deny claim line(s) items 
submitted with a GZ modifier.  
 
We looked at the file and Medicare rules. The file shows that procedure code 81291 was billed with the GZ 
modifier. This claim is therefore denied. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 90715, 90471 and 73140 for date of service 
February 7, 2023. 
 
You asked the Plan to pay for procedure codes 90715, 90471 and 73140. You say that you disagree with the 
plan's denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be billed correctly in order to be 
processed. 
 
We looked at the file and Medicare rules. Review of the file shows that code 99283 was billed on the same date 
of service with a revenue code of 450, which has a status indicator of "V". Codes 90471 and 73140 have a 
status indicator of Q1, which means these codes are not separately payable as billed. Code 90715 has a status indicator of N, which is also not separately payable. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 90471 and 73140 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 90715, 90471 and 73140 for date of service February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (81273) provided on September 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not payable 
for the billed diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that code 81273 (KIT) is considered medically 
necessary only for the diagnosis of mastocytosis.  
 
We looked at the file and Medicare rules. In this case, code 81273 was not billed with a diagnosis of 
mastocytosis. 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 (81273) provided on 
September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99232 billed for date of service February 2, 2023. 
 
You asked the Plan to pay for code 99232. You say that you do not believe this is a duplicate claim. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 22, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for code 99232 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 99232 billed for date of service February 2, 2023.