Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on May 5, 2023 to May 17, 
2023. 
 
You asked the Plan to pay for the outpatient services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the billed outpatient services are not supported in the medical record. Specifically, all related 
outpatient services on the date of an inpatient admission or the 3 preceding days of an inpatient admission 
should be bundled into the Part A inpatient services. Based on this information, we decided that Medicare rules 
for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to 
pay for outpatient services provided on May 5, 2023 to May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 12, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit (99349) provided on February 24, 2023. 
 
You asked the Plan to pay for the home visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 99349 is Home or residence visit for the evaluation and 
management of an established patient. 
 
We find that CPT code 99349 is not supported in the medical record. Specifically, a home visit was billed, 
however the claim used Place of Service 11 (office setting). Based on this information, we decided that 
Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not 
have to pay for a home visit (99349) provided on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 19, 2023. 
 
You asked the Plan to pay for the lab services. You say that the lab services should be paid as billed because 
they are supported in the documentation. 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 April 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service May 29, 
2023.  
 You asked the Plan to pay for procedure code 99291. You say that you would like the Plan to reconsider their 
denial of 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 99291 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 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service May 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 1, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 June 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want an approval for your physician's request for 
inpatient acute rehabilitation. The Plan denied your request. The Plan says you do not appear to require an 
intensive rehabilitation therapy program which generally consisting of at least 3 hours of therapy per day at 
least 5 days per week to recover to prior level of functioning. The Plan says services may be provided at a 
lower level of care.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90837) provided on July 12, 2023. 
 
You asked the Plan to pay for psychotherapy services (90837). You say that the services at issue were a 
medical necessity for the enrollee. 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 psychotherapy services 
(90837) provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service May 20, 
2023.  
 
You asked the Plan to pay for procedure code 99233. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99233 is bundled into payment for code 
90937. 
 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 99233 
is a column two code to column one code 90937 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 99233 billed for date of service May 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on June 30, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
testing (87798) provided on March 12, 2023. 
 
You asked the Plan to pay for the respiratory PCR panel testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory panels for more than 5 pathogens are 
not covered. 
 
We looked at the file and Medicare rules. In this case the panel at issue tested for more than 5 respiratory 
pathogens. Based on this information, we decided that Medicare rules for coverage of the respiratory PCR 
panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory 
polymerase chain reaction (PCR) panel testing (87798) provided on March 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0480, 80307 and 83789) billed for 
date of service June 7, 2023. 
 
You asked the Plan to pay for drug testing services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says code 83789 is not separately payable, and codes 
G0480 and 80307 are not supported in the records provided. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that providers 
performing validity testing on urine specimens utilized for drug testing should not separately bill the validity 
testing. 
 
In this case, the CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures. The CPT Code Manual definition of code G0480 is drug test(s), 
definitive, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, the records provided do not include test 
results for any presumptive or screening drug tests. Without these results, we cannot verify the services were 
provided as billed. Code G0480 is not supported, as the records show that drugs from more than 7 classes were 
tested. There is a more appropriate code to report the services provided. In addition, 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 
drug testing services (G0480, 80307 and 83789) billed for date of service June 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing provided September 27, 2022, 
billed with codes 87481, 87798, 87801.  
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and 
sensitivity. The PCR testing is considered unproven and not medically necessary. Based on this information, 
we decided that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the Urine PCR panel testing provided September 27, 2022, billed with 
codes 87481, 87798, 87801.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code L1833 billed for July 21, 2022. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims lines billed with codes without a KX, GA or 
GZ modifier will be rejected as missing information. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required KX 
modifier. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code L1833 billed for July 
21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372 billed for date of service May 18, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the code is covered by the fee schedule. The Plan 
denied your request. The Plan says the code is 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 CPT code. 
 
We looked at the file and the rules. We find that CPT code 96372 has a Q1 status indicator. Code 96372 is 
packaged when billed on the same claim as a code that has a status indicator of V, such as billed code 99284. 
This means that code 96372 is not separately payable in this case. Based on this information, we decided that 
Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 96372 billed for date of service May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2023, billed with 
codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240- 59, 81241-59, 81291-59, 81306-59, 81328-59, 
81335-59, 81238-59. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. 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 
March 8, 2023, billed with codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240- 59, 81241-59, 81291-
59, 81306-59, 81328-59, 81335-59, 81238-59.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 88341 billed for date of service June 14, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that this service was medically necessary. 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 June 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on March 7, 2023, billed with 
codes 87500, 87641, 87798, G0452, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651 
and 87653. 
 
You asked the Plan to pay for the laboratory panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the laboratory panel provided on March 7, 2023, billed with codes 87500, 87641, 87798, G0452, 87491, 87496, 
87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651 and 87653.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge day management services coded as 99239 
billed on date of service April 26, 2023. 
 
You asked the Plan to pay for 99239. You say that 99239 should be covered because it is supported in the 
medical record. The Plan denied your request. The Plan says 99239 is denied because it is not supported in the 
medical record. 
 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 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no discharge day 
management service encounter documented as performed on April 26, 2023, in the provided records. Based on 
this information, we decided that Medicare rules for coverage of 99239 have not been met. Therefore, we 
decided that the Plan does not have to pay for the discharge day management services coded as 99239 billed on 
date of service April 26, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the fluoroscopic guidance for needle placement (77002). 
 
You asked the Plan to pay for the fluoroscopic guidance for needle placement. You say that the service should 
be covered. The Plan denied your request. The Plan says that the service is not necessary. 
 
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. There is no indication as to why this service was denied. Therefore, we decided 
that the Plan has to pay for the fluoroscopic guidance for needle placement (77002).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 25, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 25, 2023.