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

 
We decided that the Plan does not have to pay for sedation (99153) provided on October 14, 2022. 
 
You asked the Plan to pay for 99153. You say that you disagree with the Plan's determination. The Plan denied 
your request. The Plan says code 99153 is a technical component only code and is not payable on a 
professional claim. 
 
The Plan must follow Medicare rules. Medicare rules say that a PC/TC indicator value of 3 means that the code 
is a technical component only code and may have an associated code for the professional component of the 
service. Code 99153 has a PC/TC indicator value of 3. 
 
We looked at the file and Medicare rules. Code 99153 has a PC/TC value of 3 and is therefore a technical 
component only code that is not paid as a professional service. There may be an associated professional code 
for payment of the professional component of this service. Based on this information, we decided that 
Medicare rules for coverage of 99153 have not been met. Therefore, we decided that the Plan does not have to 
pay for sedation (99153) provided on October 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 72131 rendered on 
March 10, 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 documentation only supports one unit of CPT 72131. 
 
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 72131 is 2. The MAI value for this code is 3. You billed 1 units of this 
code, exceeding the MUE.  
 
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 72131. Our reviewer says that the services at issue in this case are not supported by the medical records. Our reviewer found that the enrollee only had one unit of this imaging done on March 10, 2023, under the order number ending in 1080.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 72131 have not been met. Therefore, we decided that the Plan does not have to pay for an additional unit of procedure code 72131 rendered on March 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found there is no documentation of the need for a 2-midnight hospitalization. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two-dimensional (2D) oral/facial photographic image 
obtained intra-orally or extra-orally (D0350) provided on May 1, 2023. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. You say that you believe this service 
should be paid. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 13, 2023. 
Therefore, we decided that the Plan does not have to pay for the two-dimensional (2D) oral/facial photographic 
image obtained intra-orally or extra-orally (D0350) provided on May 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87088 and 87186 billed for date of service 
February 1, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the coding is 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 87088 is culture, bacterial; with isolation and 
presumptive identification of each isolate, urine. The definition of code 87186 is susceptibility studies, 
antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), 
each multi-antimicrobial, per plate. 
 
We find that CPT codes 87088 and 87186 are not supported in the medical record. Specifically, the records 
provided do not show that these lab tests were performed. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 87088 and 87186 billed for date of service February 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 18, 2022 to August 31, 2022.

You asked the Plan to pay for procedure code S9328. You say that this service 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 August 18, 2022 to August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 3, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration stating enclosed 
are medical records and referral. The Plan denied your request. The Plan says this provider is not a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 an office visit provided on April 3, 2023, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unspecified periodontal procedure (D4999). 
 
You asked the Plan to pre-approve unspecified periodontal procedure. You say that you need this to control the 
bleeding. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
unspecified periodontal procedure (D4999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 9, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for office visit. You say that you were not able to acquire a prior referral. The Plan 
denied your request. The Plan says this provider is not a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the 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 office visit provided on November 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81301-XU and 81194-XU) provided on 
March 13, 2023. 
 
You asked the Plan to pay for 81301-XU and 81194-XU. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says these codes are inclusive to 81455 and the -XU modifier 
is 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 81301 is microsatellite instability analysis of markers for 
mismatch repair deficiency. The CPT Code Manual definition of code 81194 is NUDT15 gene analysis, 
common variants. 
 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 81301-XU and 81194-XU. Our reviewer says that these 
codes do not meet criteria for payment. Our reviewer found these codes were billed with modifier -XU 
indicating an unusual non-overlapping service in addition to panel code 81455. However, the lab report does 
not include documentation to support rationale for procedure and modifier billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 81301-XU and 81194-XU have not been met. Therefore, we decided that the 
Plan does not have to pay for laboratory testing (81301-XU and 81194-XU) provided on March 13, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that the requested treatment is not considered 
medically necessary for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Imfinzi. Our reviewer says that the 
requested drug is medically necessary. Our physician reviewer found Imfinzi is FDA approved for patients 
with a least stable disease after definitive treatment for stage III disease. This enrollee has oligometastatic 
disease treated with curative intents as a stage III and meets criteria. The requested drug is reasonable and 
medically necessary.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have been met. Therefore, we decided that the Plan has to pre-approve 
Imfinzi.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 6, 2023, to 
January 27, 2023. 
 You asked the Plan to pay for the home health services. You say that the claim should not be denied in full, but 
payment should just be reduced. 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 January 6, 2023. The NOA was not received by the Plan until February 15, 
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 6, 2023, to January 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L5 kyphoplasty (22511). 
 
You asked the Plan to pre-approve L5 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria are not met as the pain is multifactorial with 
multilevel disc disease in the lumbar spine. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 L5 kyphoplasty. Our reviewer says that 
you do not meet criteria for coverage. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height loss, kyphotic deformity, 
or a severe impact on daily activities. Moreover, there is magnetic resonance imaging corroboration of other 
plausible causes of the back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L5 kyphoplasty (22511).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization of left iliac artery with angioplasty 
(37220). 
 
You asked the Plan to pre-approve revascularization of left iliac artery with angioplasty. You say that this is 
medically necessary. The Plan denied your request. The Plan says this 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 pre-approve revascularization of left iliac artery with 
angioplasty. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found on recent evaluation there is documentation that the 
enrollee denies claudication. There is no evidence of limb threat. There is documentation of palpable pedal 
pulses, and, on most recent angiography, the iliac arteries were patent without evidence of stenosis.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization of left iliac artery with angioplasty have not been met. 
Therefore, we decided that the Plan does not have to pre-approve revascularization of left iliac artery with 
angioplasty (37220).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing, 22 or more drug classes (G0483) 
provided December 15, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please review the attachment and process the 
claim for payment. The Plan denied your request. The Plan says the records do not support the service 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 G0483 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the laboratory service. Our reviewer says that the 
documentation submitted does not meet the criteria for coverage. Our reviewer found the medical records 
submitted includes a laboratory report to support service billed, however a physician order for service provided 
was not found in medical record, and therefore procedure performed 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 definitive drug testing, 22 or more drug classes (G0483) provided December 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospitalist physician visits provided on April 25, 2023 and 
April 26, 2023. 
 
You asked the Plan to pay for physician visits. You say that these codes were billed for the correct level of 
service. The Plan denied your request. The Plan says the records do not support a high level of medical 
decision-making or the time requirements of these codes. 
 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. The CPT Code Manual definition of code 99233 is subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
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 physician visits. Our reviewer says that these codes do not 
meet criteria for payment. Our reviewer found the records do not support this level of coding. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physician visits have not been met. Therefore, we decided that the Plan does not 
have to pay for hospitalist physician visits provided on April 25, 2023 and April 26, 2023.