Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Xiaflex. 
 
You asked the Plan to pre-approve the medication. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says that the medication is not covered as a medical benefit 
under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the medication. Our reviewer says that 
the medication is medically reasonable and necessary. Our physician reviewer found Xiaflex is Food and Drug 
Administration-approved for the treatment of Dupuytren's contracture of finger, with a palpable cord. Provided 
records document this condition in this case. Records document no contraindications to the use of Xiaflex. 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve Xiaflex.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95720 billed for date of service August 24, 
2023.  
 You asked the Plan to pay for procedure code 95720. You say that the service was billed correctly and should 
be paid. 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 95720 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 95720 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95720 billed for date of service August 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87506, 87500, and 87798 billed for date of 
service September 12, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. There is no evidence that multiple procedures, multiple 
methodologies, or multiple kits were used in this case. As such, a single code with one unit of service should be 
used. Additionally, the records do not show that the enrollee met the criteria for panel testing to treat the 
enrollees condition. Based on this information, we decided that Medicare rules for coverage of the testing 
panel have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87506, 
87500, and 87798 billed for date of service September 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92921 billed for date of service August 18, 
2023. 
 
You asked the Plan to pay for procedure code 92921. You say that this code is a separate service. The Plan 
denied your request. The Plan says procedure code 92921 is considered bundled and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 92921 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 92921 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 92921 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92921 billed for date of service August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the podiatry services provided on August 
14, 2023. 
 
You asked the Plan to reduce the copayment for the podiatry services. You say that you should only have a $40 
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 $75 
copayment for out-of-network podiatry services. 
 
You have been asked to pay a $75 copayment for the podiatry services. This item/service falls within the out-
of-network podiatry 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. Therefore, we decided that the Plan does not have to reduce the copayment for the 
podiatry services provided on August 14, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43235 billed for date of service March 28, 
2023.  
 
You asked the Plan to pay for procedure code 43235. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 43235 is bundled into payment for code 43240. 
 
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 43235 
is a column two code to column one code 43240 with a modifier indicator of 0. The column two code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 43235 billed for date of service March 28, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve the 6 physical therapy (PT) visits at California Rehab and Sports 
Therapy. 
 
You asked the Plan to pre-approve the 6 PT visits. You say that you do not agree with the denial of the PT 
visits. The Plan denied your request. The Plan says that according to the Local Coverage Article (LCA) 
A53065, requests for PT require a prescription and a treatment plan, but the Plan did not receive those orders 
from your physician. 
 
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. We find that the Plan's reasoning for their decision is not appropriate. The Plan 
eventually did receive your physician's order for the requested services, but never submitted them to us for 
review. Also, the cited criteria found in LCA A53065 is for an improper jurisdiction and cannot be applied to 
this case. Therefore, we decided that the Plan has to pre-approve the 6 physical therapy (PT) visits at California 
Rehab and Sports Therapy.  
 
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 the monitored anesthesia care provided on January 6, 2023. 
 
You asked the Plan to pay for the anesthesia care. The Plan denied your request. The Plan says the billed 
diagnosis code is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only certain diagnosis codes are considered 
medically necessary for monitored anesthesia care. 
 
We looked at the file and Medicare rules. The billed diagnosis code, M54.16, is not covered for monitored 
anesthesia care per LCA A57361. Based on this information, we decided that Medicare rules for coverage of 
the anesthesia care have not been met. Therefore, we decided that the Plan does not have to pay for the 
monitored anesthesia care provided on January 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on July 27, 
2023. 
 
You asked the Plan to pay for the MRI. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the claim must be submitted to the enrollee's primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the Plan 
directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held 
responsible for the MRI until the primary insurer has denied the claim for these services. Therefore, we decided 
that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on July 27, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service July 19, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. 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 27560 
provided on July 7, 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 99285 for date of 
service July 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed for date of service April 6, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were sent. The Plan denied your 
request. The Plan says the billed codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. The records provided do not include lab results that support the 
billing of presumptive and definitive drug testing. Based on this information, we decided that the Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
testing billed for date of service April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on July 10, 2023. 
 
You asked the Plan to pay for physicians services. You say that you did not realize there would be a limit on 
the Convenience Care benefit for out of state coverage. 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 physicians services 
provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on May 03, 2023. 
 
You asked the Plan to pay for the office visit (99214). You say that the service was 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 the office visit (99214) 
provided on May 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service July 16, 
2023, to August 12, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that S9328 should be paid as billed because it 
was medically necessary. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service July 16, 2023, to August 12, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic colonoscopy 
provided on August 28, 2023. 
 
You asked the Plan to waive the copayment for an in-network diagnostic colonoscopy. You say that this was a 
screening colonoscopy and should not have a ccopayment. 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 $250 
copayment for outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. 
 
You have been asked to pay a $250 copayment for an in-network diagnostic colonoscopy. This item/service falls within the outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility 
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 an in-network diagnostic 
colonoscopy provided on August 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 26, 2023. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on May 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87491, 87496, 
87529, 87532, 87563, 87591, 87481, 87651, 87653, 87500, 87641, G0452, and 87798 for date of service 
August 30, 2023. 
 
You asked the Plan to pay for the laboratory services billed with codes 87491, 87496, 87529, 87532, 87563, 
87591, 87481, 87651, 87653, 87500, 87641, G0452, and 87798. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with codes 87491, 87496, 87529, 87532, 87563, 
87591, 87481, 87651, 87653, 87500, 87641, G0452, and 87798 for date of service August 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on July 12, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should only be 
billed with one code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on July 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation billed for date of service June 
16, 2023. 
 
You asked the Plan to pay for the billed services. You say that the coding is correct. 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 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 R52 has an Excludes1 note in relation to diagnosis code group R10.-. This 
means that diagnosis codes R52 and R10.9 cannot be reported together. Based on this information, we decided 
that the Medicare billing rules for the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance transportation billed for date of service June 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81456) provided on February 20, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is covered when the enrollee has  
either recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer, and has decided to seek 
further cancer treatment (e.g., therapeutic chemotherapy). 
 
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 genetic testing. Our reviewer says that 
the records do not support the billed testing. Our physician reviewer found the provided documentation does 
not document what, if any, further treatment the enrollee will seek. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (81456) provided on February 20, 2023.