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

 
We decided that the Plan does not have to pay for procedure code 96365 billed for date of service May 5, 2023. 
 
You asked the Plan to pay for procedure code 96365. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 96365 is bundled into payment for code 70496.  
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 96365 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 96365 billed for date of service May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, evaluation, and management of the critically ill 
or critically injured patient; first 30-74 minutes (99291) provided on April 6, 2023. 
 
You asked the Plan to pay for a critical care evaluation. You say that you request reconsideration for payment 
on this claim due to the enrollee having organ failure. 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 I95.9 has an Excludes1 note in relation to R57.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for a critical care evaluation have not been met. Therefore, we decided that the Plan does not have to pay 
for critical care, evaluation, and management of the critically ill or critically injured patient; first 30-74 minutes 
(99291) provided on April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 4, 2023, billed with 
procedure codes 73630 and 96372. 
 
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 billed codes are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
 
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. Codes 73630 and 96372 are not separately payable as they have a Q1 status indicator and were billed with code 99284 which has a status indicator of V. 
Therefore, we decided that the Plan does not have to pay for practitioner services provided on May 4, 2023, 
billed with procedure codes 73630 and 96372.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test provided on August 18, 
2022. 
 
You asked the Plan to pay for the GeneSight Psychotropic test. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this test is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter 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 pay for the GeneSight Psychotropic test. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that based on review 
the records provided the medication has not been found to be useful in assistance with the patients symptoms. 
The Medicare LCD L38394 requires the enrollee to be tried on at least one medication. The ordering 
psychiatrist must be board certified in psychiatry or neuropsychiatry. The ordering physician for this test is not 
a psychiatrist and is not boarded in psychiatry or neuropsychiatry. Documentation does not show the 
improvement with the medication as the medication was not found to be useful. Utilizing the information from 
the LCD, this enrollee does not meet the criteria for GeneSight Psychotropic Assay and is not considered 
medically necessary and reasonable in the treatment of this individual. 
 
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 GeneSight Psychotropic test have not been met. Therefore, we decided that 
the Plan does not have to pay for the GeneSight Psychotropic test provided on August 18, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic radiosurgery (SRS) 77370, 77372, 77470). 
 
You asked the Plan to pre-approve SRS. You say that SRS is medically necessary. The Plan denied your 
request. The Plan says that Medicare requirements state that radiosurgery is not appropriate for your brain 
cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SRS. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found SRS for a single brain metastasis is standard of care as recommended by American Society for 
Therapeutic Radiology and Oncology (ASTRO) Choosing Wisely, National Comprehensive Cancer Network 
(NCCN) guidelines, and a multitude of other societies and groups. The LCD criteria are met. An untreated 
brain metastasis is potentially life threatening. SRS would afford high likelihood of disease control.  Enrollees with poor performance status (Karnofsky Performance Status less than 40 or an Eastern Cooperative 
Oncology Group (ECOG) Performance greater than 3), note that the higher a Karnofsky Performance Status is, 
the better an enrollee is doing. However, the lower an ECOG Performance Status is, the better an enrollee is 
doing. The enrollees performance status is described as good. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SRS have been met. Therefore, we decided that the Plan has to pre-approve 
stereotactic radiosurgery (SRS) 77370, 77372, 77470).  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90832 billed for May 9, 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 claim was billed with the incorrect place of service (POS). 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 30 for a 
skilled nursing facility (SNF); however, the file shows that the services were rendered in a federally-qualified 
health center (FQHC) and should have been billed with POS code 50. Therefore, we decided that the Plan does 
not have to pay for procedure code 90832 billed for May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0482) provided on June 5, 2023. 
 
You asked the Plan to pay for definitive drug testing. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that when a definitive/quantitative test is performed, 
the record must show that an inconsistent positive finding was noted on the presumptive testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of definitive drug testing have not been met. Specifically, there is no evidence in the case record of 
presumptive testing having been performed prior to the definitive testing at issue. 
  Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0482) provided on June 
5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on May 3, 2023. 
 
You asked the Plan to pay for foot orthotics. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics 
provided on May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 
provided on June 5, 2023. 
 
You asked the Plan to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. You say that the 
shot was recommended by your doctor. The Plan denied your request. The Plan says the Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccination and administration is not covered under Medicare Part B when it is 
preventive, it is only under the Medicare Part D prescription drug benefit. However, your Health Plan does not 
have the Medicare part D prescription drug benefit. The Health Plan cannot help with the payment for this non-
covered vaccination. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria Toxoids and Acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay 
for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine provided on June 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 19301, 38525, and 38900 for date of service 
May 31, 2023. 
 
You asked the Plan to pay for procedure codes 19301, 38525, and 38900. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed 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. 
 
We find that CPT codes 19301, 38525, and 38900 are not supported in the medical record. Specifically, the 
documentation did not include an operative report for this date of service. This means these codes cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of procedure codes 19301, 
38525, and 38900 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 19301, 38525, and 38900 for date of service May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
July 14, 2023, and billed with codes 87150, 87481, 87798, 87641, 87653, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on July 14, 2023, and billed with codes 87150, 87481, 87798, 87641, 87653, and 87801.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on May 26, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 20610 
provided on May 26, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 provided on 
May 26, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the Comprehensive Full Body 3D Kinetic Motion 
Analysis (code 0693T) billed for date of service June 5, 2023.  
 
You asked the Plan to hold you harmless for code 0693T. You say that your doctor performed this test during 
your wellness visit.  You said that you didn't ask for this test and shouldn't be held responsible for it. The Plan 
denied your request. The Plan says that this service is considered experimental/investigational and is therefore 
non-covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided code 0693T by a contract provider. The file does not show that the Plan provided notice 
that code 0693T would not be covered in advance.  In fact, the only Notice of Denial that the Plan issued to you 
was well after the date of service. Under Medicare rules, this means code 0693T is considered approved by the 
Plan. The provider who performed this service is a contract provider with the Plan.  Contract providers are 
expected to know which services are covered and which are not. This contract provider failed to confirm with 
the Plan that this service may not be covered prior to it being rendered. You cannot be held responsible for this 
provider's failure.  Therefore, we decided that the Plan has to hold you harmless for the Comprehensive Full 
Body 3D Kinetic Motion Analysis (code 0693T) billed for date of service June 5, 2023.   
 
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 pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that you are requesting reconsideration 
for the denied claim. The Plan denied your request. The Plan says the requested services are not reasonable and 
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 pre-approve neuropsychological testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation showed the enrollee to have a left anterior choroidal 
infarct April 2023 along with anxiety. The enrollees speech deficits have improved, and the enrollees 
speech/language is fluent with no aphasia. There is no evidence of paraphasia or preservation of language pattern. The enrollees attention and concentration are normal The enrollee had a mini mental status exam 
which was 29/30. Utilizing the criteria from LCD L33632 that this testing is intended to diagnose and 
characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain 
including detection of neurologic disease based on quantitative assessment of neurocognitive abilities, 
differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of 
central nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous 
system disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or 
management strategies among individuals with neuropsychiatric disorders, this enrollee does not meet the 
criteria for psychological and neuropsychological testing as the enrollees speech has improved and it is unclear 
how neuropsychological testing would guide speech and occupational therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on June 19, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that you are asking for the submitted appeal be 
reviewed. 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 acupuncture services 
provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on July 4, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the evaluation and management. You say that your physician rendered medical 
care for this patient in the facility and as requested by the facility. You say that you should not be penalized for 
providing medical services that were medically necessary. You say that the medical records provided support 
that the services in dispute were medically necessary. The Plan denied your request. The Plan says the OON 
services were not pre-approved. 
 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 evaluation and management services provided on 
July 4, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided on 
November 02, 2022, to November 08, 2022. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that you should not have 
to pay this 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 $375 
copayment for inpatient hospital care. 
 
You have been asked to pay a $375 copayment for an in-network inpatient stay. This item/service falls within 
the inpatient hospital 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. You have been asked to pay a total of $1,875 for the inpatient hospital stay ($375 
copayment x 5 days = $1,875). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided on 
November 02, 2022, to November 08, 2022.