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

 
We decided that the Plan does not have to pay for medical services provided on March 27, 2023.  
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported 
together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that N18.6 has an Excludes1 note in relation to N19. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (96365, 96366) provided on May 19, 2023. 
 
You asked the Plan to pay for infusion services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered under Medicare. 
 
 
 We looked at the file and Medicare rules. This service is non-covered. Based on this information, we decided 
that Medicare rules for coverage of infusion services have not been met. Therefore, we decided that the Plan 
does not have to pay for infusion services (96365, 96366) provided on May 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 29, 2022, to June 
27, 2022. 
 You asked the Plan to pay for the home health services. You say that you need payment for these services. The 
Plan denied your request. The Plan says the NOA was not received. 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 NOA was not received by the Plan. As a result, 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 May 29, 
2022, to June 27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (85025, 80053, 82043 and 36415) provided on June 
2, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were reported appropriately, and 
you confirmed with Medicare that the enrollee was not in a skilled nursing facility at the time of services. The 
Plan denied your request. The Plan says that the payment for these services is bundled into the skilled nursing 
facility payment. 
 
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. Specifically, the Plan has provided no evidence to support that these services 
would be bundled into any other payment or that they have already been paid to another facility or entity. The 
Plan has not substantiated their denial in this case. Therefore, we decided that the Plan has to pay for laboratory 
services (85025, 80053, 82043 and 36415) provided on June 2, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 24, 2023, to 
January 25, 2023, billed with procedure codes 99223, 99232, and G8427. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid place of 
service. 
 The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. This claim was inappropriately billed with 
place of service code 21 as documentation shows that the enrollee was registered outpatient observation on the 
dates of service in question. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on January 24, 2023, to January 25, 2023, billed with procedure codes 99223, 99232, and G8427.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) and an intraoral complete 
series of radiographic images (D0210) provided by an out-of-network provider on December 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting payment for the dental 
services that were provide to the enrollee. The Plan denied your request. The Plan says that the alternate benefit 
has been provided for the comprehensive oral evaluation. Also, the enrollee's benefit for the intraoral 
radiographic images has already been exhausted. 
 
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. 
 
We looked at the contract between the enrollee and the Plan. We did not see where the contract says that an 
alternate benefit can be applied for dental services, and we also did not see where the intraoral complete series 
of radiographic images are limited to 1 time per 3-year period. The Plan contract does not clearly say that an 
alternate benefit can be applied to dental services and that the intraoral complete series of radiographic images 
are limited to 1 time per 3-year period. This means that the Plan did not follow Medicare rules for disclosure of 
the enrollees dental benefits. Therefore, we decided that the Plan has to pay for a comprehensive oral 
evaluation (D0150) and an intraoral complete series of radiographic images (D0210) provided by an out-of-
network provider on December 22, 2022.  
  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99221 billed for date of service December 
13, 2022.  
 
You asked the Plan to pay for procedure code 99221. You say that this service was originally billed as code 
99223 and you submitted a corrected claim.  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 99221 is 1. The MAI value for this code is 3. You billed 2 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 99221 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99221 billed for date of service December 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Automatic Implanted Cardiac Defibrillator (AICD) 
(33249). 
 
You asked the Plan to pre-approve AICD. 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 follows Medicare rules. Medicare rules say that ICDs are covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve AICD. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found review of clinical documents does not 
show that the enrollee meets implant criteria for defibrillator insertion according to current guidelines. In the 
absence of such documentation, implantation of an automatic defibrillator would not be considered medically 
necessary in the management of this 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 AICD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Automatic Implanted Cardiac Defibrillator (AICD) (33249).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on May 7, 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 billed code - CPT 99285 - is not substantiated by the clinical documentation. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high 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 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 severity of illness does not 
meet this level of billing. The records do not support a high 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) rendered on May 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenic stimulator (E0748). 
 
You asked the Plan to pre-approve an osteogenic stimulator. 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 follows Medicare rules. Medicare rules say that a spinal electrical osteogenesis stimulator (E0748) is 
covered only when certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an osteogenic stimulator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found you do not have any of the 
indications and 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 an osteogenic stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an osteogenic stimulator (E0748).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on April 26, 2023. 
 
You asked the Plan to pay for emergency room services. You say that this should be covered. The Plan denied 
your request. The Plan says the provider of the services at issue is not enrolled 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 emergency room services provided on 
April 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for TissueCypher Barrett's Esophagus assay (0108U) provided 
on February 6, 2023. 
 
You asked the Plan to pay for TissueCypher Barrett's Esophagus assay. You say that this test was necessary 
and reasonable. The Plan denied your request. The Plan says this test 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 TissueCypher Barrett's Esophagus assay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this test does not meet Medicare criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TissueCypher Barrett's Esophagus assay have not been met. Therefore, we 
decided that the Plan does not have to pay for TissueCypher Barrett's Esophagus assay (0108U) provided on 
February 6, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97129 and 97130 billed for May 15, 2023, 
to May 24, 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 provider cannot bill for physical therapy services. 
 
The Plan must follow Medicare rules. The rules say that outpatient rehabilitation claims must be billed with the 
GN, GO, or GP modifier.  
 
We looked at the file and Medicare rules. The file shows that the speech therapy services were not billed with the required GN 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 codes 
97129 and 97130 billed for May 15, 2023, to May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87801) provided on November 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. 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 (87801) provided on November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on February 28, 2023. 
 
You asked the Plan to pay for the eye refraction. You say that the enrollees infectious disease doctor ordered 
and referred the enrollee to the eye doctor for an eye exam to make sure the medication she was taking was not 
affecting her eyesight. The Plan denied your request. The Plan says eye refractions performed in conjunction 
with Medicare covered eye exams are not covered. The Plan says all services on the claim were not denied, the 
eye exam is a covered service by the Plan and paid accordingly with the members benefits and copay. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87481, 87798) provided on 
November 9, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that please see attached medical records for 
review and reconsideration. 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 (87481, 87798) provided 
on November 9, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 46221 billed for date of service March 8, 
2023.  
 
You asked the Plan to pay for procedure code 46221. You say that these services are supported as billed. 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 46221 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 46221 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 46221 billed for date of service March 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87184, 87500, 87481, 87641, 87150, 87798, 
87653 and 87640 billed for April 24, 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 procedure codes 87184, 87500, 87481, 87641, 87150, 87798, 87653 and 87640 are 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 87184 is susceptibility studies, antimicrobial agent; disk 
method, per plate (12 or fewer agents). The definition of code 87500 is infectious agent detection by nucleic 
acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe 
technique. The definition of code 87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique. The definition of code 87641 is infectious agent detection by nucleic acid 
(DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of 
code 87150 is culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, 
per culture or isolate, each organism probed. The definition of 87798 is infectious agent detection by nucleic 
acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. The definition of code 
87653 is infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe 
technique. The definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique. 
 
We find that CPT codes  87184, 87500, 87481, 87641, 87150, 87798, 87653 and 87640 are not supported in the 
medical record. Specifically, the file shows a panel of tests was performed and there is a more appropriate 
single code for the services. 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 codes 
87184, 87500, 87481, 87641, 87150, 87798, 87653 and 87640 billed for April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient intravenous insulin therapy (OIVIT) provided on 
April 25, 2023. 
 
You asked the Plan to pay for OIVIT. You say that you are appealing with records to support these codes. The 
Plan denied your request. The Plan says these codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of OIVIT have not been met. Therefore, we decided that the Plan does not have to pay for outpatient 
intravenous insulin therapy (OIVIT) provided on April 25, 2023.