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

 
We decided that the Plan does not have to pay for the laboratory service (81433) provided April 27, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that this testing should be covered  The Plan 
denied your request. The Plan says 81433 was not billed with -59 to support separate distinct testing. 
 
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 81433 is hereditary breast cancer-related disorders (eg, 
hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion 
analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11.  
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 laboratory service. Our reviewer found the 
documentation submitted was reviewed and does not meet criteria. CPT code 81433 cannot be verified. The 
laboratory report included documentation of 2 genes analyzed, which was reported and reimbursed with code 
81432. 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (81433) provided April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 10, 2022. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with proof of timely filing. The Plan 
denied your request. The Plan says the corrected claim was not received within the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for lab tests was not filed until February 27, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for laboratory testing provided on January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 23, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. 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 laboratory services 
provided on March 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computer assisted navigation. 
 
You asked the Plan to pre-approve the computer assisted navigation. You say that the enrollee has had an 
inadequate response to conservative treatments. You say that this procedure is the only viable option to address 
the enrollee's deteriorating spinal health. You also say that the enrollee's pain has significantly impacted their 
ability to perform activities of daily living (ADLs). The Plan denied your request. The Plan says there is no 
proof this imaging would benefit the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the computer assisted navigation. Our 
reviewer says that the requested computer assisted navigation is not considered medically reasonable and 
necessary in this case. Our physician reviewer found computer assisted lumbar surgery has not been shown to 
be more effective and safer than conventional open surgery. In this case, there is a previous laminectomy only. 
There is no need for computer assist. Therefore, the reviewer found that the requested computer assisted 
navigation is 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 computer assisted navigation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the computer assisted navigation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary for the enrollee 
to receive the care needed. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on May 12, 2023. 
 
You asked the Plan to pay for lab tests. You say that the coding and diagnosis are both approved by Medicare. 
The Plan denied your request. The Plan says there is a more appropriate code that could be used which is 
87801. 
 
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 87481 is candida species, amplified probe technique. 
 
The CPT Code Manual definition of code 87491 chlamydia trachomatis, quantification. 
 
The CPT Code Manual definition of code 87500 is vancomycin resistance (eg, enterococcus species van A, van 
B), amplified probe technique.  
The CPT Code Manual definition of code 87563 is mycoplasma genitalium, amplified probe technique. 
 
The CPT Code Manual definition of code 87640 is staphylococcus aureus, amplified probe technique. 
 
The CPT Code Manual definition of code 87641 is staphylococcus aureus, methicillin resistant, amplified 
probe technique. 
 
The CPT Code Manual definition of code 87653 is streptococcus, group B, amplified probe technique. 
 
The CPT Code Manual definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), 
not otherwise specified, amplified probe technique, per organism probed. 
 
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 lab tests. Our reviewer says that these codes do not meet 
criteria for payment. For codes 84781, 87491, 87563, 87653, 87640, and 87641 our reviewer found that the 
provider tested multiple organisms and reported each separately. In this case, a panel procedure code should be 
reported for the services provided. For code 87500 our reviewer found that this procedure falls under the range, 
infectious agent detection, and would be included in the multiple organism panel when reported correctly. For 
code 87798 our reviewer found that this procedure would be included in the panel procedure code when 
reported correctly. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on May 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 16, 2023, to 
February 8, 2023. 
 You asked the Plan to pay for the home health services. You say that the claim is not lacking any information. 
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 December 15, 2022. The NOA was not received by the Plan until April 17, 
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 January 16, 2023, to February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each laryngoscopy procedure provided on 
April 24, 2023, to May 01, 2023. 
 
You asked the Plan to reduce the copayment for each laryngoscopy procedure. You say that you should not 
have a surgical copayment. 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 a $370 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $370 copayment for each laryngoscopy procedure. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 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. The total amount you owe is $740 
($370 copayment x 2 surgeries = $740). Therefore, we decided that the Plan does not have to reduce the 
copayment for each laryngoscopy procedure provided on April 24, 2023, to May 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0241U the laboratory service coded as 
87486, 87581, 87798 and 87633 provided March 23, 2023. 
 
You asked the Plan to pay for procedure code 0241U the laboratory service. You say that you are requesting 
reconsideration and reprocessing towards payment of this claim. The Plan denied your request. The Plan says 
the laboratory services are not medically necessary. The benefit for this service is included in the 
payment/allowance for another 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. 
 
We looked at the file and Medicare rules. In this case, the respiratory pathogen panel performed had more than 
5 pathogens on it which does not meet Medicare reasonable and necessary requirements. We also confirmed 
that code 87633 is a column II code to column I code 0241U. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 0241U the laboratory service coded as 87486, 87581, 87798 and 
87633 provided March 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on April 18, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were not 
aware the cost share would be so high and you are unable to afford to pay. 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 a $200 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $200 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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 
computed tomography (CT) scan provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on December 29, 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 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 code 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older."  
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 documentation submitted did 
not indicate the presence of an independent trained observer during the procedure for the billed services nor the 
total intra-service time for the moderate sedation services. There was documentation that Versed and Fentanyl 
were administered, however, there was no anesthesiology record documenting intraoperative/intra-procedural 
monitoring of this patient (including blood pressure, heart rate, respiratory rate, EKG, oxygen saturation). The 
review has determined that the use of CPT 99152 is not supported by the records provided. 
 
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 moderate sedation services (procedure code 99152) rendered on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 11, 2023, billed with 
procedure codes 99223-57 and 49255-59. 
 
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 payment for code 49255 is included in the 
payment of code 49594. The Plan also says code 99233 was billed without an appropriate modifier. 
 
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. In this case, we have confirmed that code 49255 is a column II code 
to column I code 49594 with a modifier indicator of 0. The column II code is therefore not payable. Procedure 
code 99233 was not billed with an appropriate modifier and is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the practitioner services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on April 11, 
2023, billed with procedure codes 99223-57 and 49255-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 13, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. 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 the office visit provided 
on April 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 31, 2022, to 
April 29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was submitted 
multiple times. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 31, 2022, to April 
29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on April 13, 2021. 
 
You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says that the Plan 
found no good cause to make an exception to the 12-month timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the anesthesia services was not filed until April 11, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for anesthesia services provided on April 13, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on March 14, 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 this level of care was 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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for 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 documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level. 
 
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 99284) rendered on March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care office visit provided on 
April 21, 2023. 
 
You asked the Plan to waive the copayment for the urgent care office visit. You say that you were referred to 
the emergency room, and should not have to pay for this visit. 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 a $65 
copayment for urgently needed services. 
 
You have been asked to pay a $65 copayment for the urgent care office visit. This item/service falls within the 
urgently needed services 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. The record shows this claim was approved and you are responsible for the cost share 
amount. Therefore, we decided that the Plan does not have to waive the copayment for the urgent care office 
visit provided on April 21, 2023.