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

 
We decided that the Plan does not have to pay for the telehealth critical care services provided on February 3, 
2023, billed with code G0508-GO. 
 
You asked the Plan to pay for the services as billed. You say that these services were billed correctly.  The Plan 
denied your request. The Plan says the modifier -GO was used which is not valid for use with this code.  
 
The Plan must follow Medicare rules. Medicare rules say that telehealth services furnished for purposes of 
diagnosis, evaluation, or treatment of symptoms of an acute stroke may be billed with modifier -G0. 
 
We looked at the file and Medicare rules. in this case, the billed modifier was -GO, not -G0. Modifier -GO is 
not appropriate for these services. Based on this information, we decided that Medicare rules for coverage of 
the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
telehealth critical care services provided on February 3, 2023, billed with code G0508-GO.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on March 
22, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that this is supported in the 
records. The Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on March 
22, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941) provided 
from April 20, 2023, through June 16, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services at issue in this case are not a 
covered benefit by Medicare or the Plan.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at this case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the Plan confirmed with your provider that 
chiropractic maintenance care was provided to you in this case. Chiropractic maintenance care is not a 
Medicare covered benefit. Therefore, we decided that the Plan does not have to pay for the chiropractic 
manipulative treatments (98941) provided from April 20, 2023, through June 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 64488 rendered on May 8, 2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not indicate that a distinct procedure of CPT 64488 was performed on a separate 
patient encounter on the billed date of 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 64488 is "Transversus abdominis plane (TAP) block 
(abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when 
performed)." 
 
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 provider reported two units 
for a procedure with only one allowable unit of service. The code descriptor identifies this procedure as a 
bilateral procedure, so when performed bilaterally at the same operative session report, only one unit of service 
should be reported. In this case, the service was incorrectly reported. 
 
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 two units of procedure code 64488 rendered on May 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83520 billed for date of service April 10, 
2023. 
 
You asked the Plan to pay for code 83520. You say that this service was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says this code 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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified.  
 
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 code 83520. Our reviewer says that the criteria for coverage 
have not been met. Our reviewer found the procedure report does not include the procedure performed to support a "not otherwise specified." Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 83520 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 83520 billed for date of service April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798, and 87801 rendered 
on January 26, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique  
CPT 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
CPT 87801: 
 
Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique 
 
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 laboratory report does not 
include documentation to support the rationale of reporting modifier XU for unusual non-overlapping service. 
Therefore, the codes cannot be verified. 
 
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 procedure codes 87481, 87653, 87798, and 87801 rendered on January 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 rendered on 
January 27, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says these codes are not reimbursable separately. 
 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 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 laboratory report does not 
include to documentation to support using modifier XU for unusual non-overlapping services. The denied 
codes and the modifier cannot be verified. 
 
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 procedure codes 87481, 87653, and 87798 rendered on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99213 and 20611 rendered on April 17, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 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 in terms of CPT 99213, the 
provider reported this with modifier -25. However, the records did not support an evaluation and management 
that was significant and separately identifiable from CPT 20611. Additionally, the documentation submitted 
shows that CPT 20611 was billed twice. The plan approved one unit, but the records do not support reporting 
an additional service. 
 
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 procedure codes 99213 and 20611 rendered on April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure codes 83520, 87798) rendered 
on December 4, 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 the denied codes remain 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 the denied codes is: 
 
CPT 83520: 
 
Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
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 both of these codes represent 
code definitions of "not otherwise specified." The medical record does not include documentation of the 
specific procedures reported for these codes, and therefore cannot be verified. 
 
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 laboratory services (procedure codes 83520, 87798) rendered on December 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 Procrit have been met. Specifically, medical records were requested but not received. Medical necessity cannot be established without this 
documentation. Therefore, we decided that the Plan does not have to pre-approve Procrit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for plasmapheresis provided on April 7, 2023. 
 
You asked the Plan to pay for plasmapheresis. You say that plasmapheresis was medically necessary. The Plan 
denied your request. The Plan says the requested plasmapheresis is experimental and does not meet the 
Medicare NCD coverage criteria.  
 
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 plasmapheresis. Our reviewer says that the 
requested plasmapheresis is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that limited medical records are provided but the procedure was done for a diagnosis of chronic 
idiopathic polyneuritis. Not enough information is provided to determine medical necessity and rationale for 
the plasmapheresis. The service was not reasonable or medically 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 plasmapheresis have not been met. Therefore, we decided that the Plan does not 
have to pay for plasmapheresis provided on April 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on April 5, 2023, 
billed with code 88305-26-PT. 
 
You asked the Plan to pay for the services as billed. You say that this was billed with modifier -PT to indicate 
the pathology services were done in conjunction with a screening colonoscopy which became diagnostic. The 
Plan denied your request. The Plan says modifier -PT cannot be used with code 88305. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -PT may be used with certain codes to 
waive the deductible when associated with a screening-turned-diagnostic colonoscopy. 
 
We looked at the file and Medicare rules. Code 88305 is not among the codes noted to be billable with modifier 
-PT. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology services provided 
on April 5, 2023, billed with code 88305-26-PT.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87801 (3 units), 87150, 87481, 87641, 
87653 and 87798 billed for date of service February 3, 2023.  
 
You asked the Plan to pay for codes 87801 (3 units), 87150, 87481, 87641, 87653 and 87798. You say that 
these services were necessary and are supported in the medical record. The Plan denied your request. The Plan 
says these codes are not supported 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. 
 
In this case, we have confirmed that code 87150 is a column II code to column I code 87500. We have also 
confirmed that codes 87481, 87641, 87653 and 87798 are column II codes to column I code 87801; however, 
these codes were billed with a modifier.  
 
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 codes 87801, 87150, 87481, 87641, 87653 and 87798. Our 
reviewer says that the criteria for coverage have not been met. For CPT 87801, our reviewer found that the 
healthcare provider reported 3 units for service; however, the procedure code represents a multiple organisms 
panel. Only one unit of service would be billed for the procedure when the same methodology is performed. 
 
For codes 87150, 87481, 87641, 87653, and 87798, our reviewer found that the healthcare provider reported 
each procedure code with appended modifier XU (unusual non-overlapping service) to bypass the NCCI Edit; 
however, the laboratory report does not include documentation to support rationale of unusual non-overlapping 
service, and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 87801, 87150, 87481, 87641, 87653 and 87798 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87801 (3 units), 87150, 87481, 
87641, 87653 and 87798 billed for date of service February 3, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 31, 
2023, to February 25, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were unaware of the copayment 
and cannot afford to pay the cost share applied. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 
copayment per day for days 1 to 20, a $80 copayment per day for days 21 to 44, and $0 copayment for days 45 
to 100 for SNF care.  
 You have been asked to pay $800 for a SNF stay ($20 per day x 20 days = $400 and $80 per day x 5 days = 
$400). This item/service falls within the SNF care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a SNF stay provided from January 31, 2023, to February 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monthly rental charge for a hospital bed with mattress 
coded as E0260 for date of service March 14, 2023.  
 
You asked the Plan to pay for the hospital bed rental charge. You say that the enrollee has no other hospital 
bed, so this should not be considered duplicate.  The Plan denied your request. The Plan says the enrollee 
received a dry pressure mattress on December 14, 2022. As such, billing for a hospital bed with mattress would 
represent duplicative payment for the mattress.  
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 In this case, the code used for the hospital bed, E0260, includes reimbursement for a mattress. The Plan has 
shown however that the enrollee received a mattress E0184 on a prior claim. As such, a hospital bed including 
a mattress would duplicate payment for the mattress.  Therefore, we decided that the Plan does not have to pay 
for the monthly rental charge for a hospital bed with mattress coded as E0260 for date of service March 14, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, and 87653, and 
87798 rendered on January 17, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 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 provider reported these codes 
with modifier XU for unusual and non-overlapping services, to bypass the edit with CPT 87150 and CPT 
87801. However, the laboratory report does not include documentation to support the rationale of using this modifier. 
 
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 procedure codes 87150, 87481, 87641, and 87653, and 87798 rendered on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on December 16, 2022, by 
an OON provider.  
 
You asked the Plan to pay for the chiropractic services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 chiropractic services provided on December 
16, 2022, by an OON provider.