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

 
We decided that the Plan does not have to pay for practitioner services provided on June 16, 2023, billed with 
procedure codes 99231-24 and 99233-24. 
 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 documentation does not support the billed 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, we have confirmed that codes 99231-24 and 99233-24 are column II codes to column I codes 
44120 and 49402; however, 99231-24 and 99233-24 were billed with a modifier.  
 
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 practitioner services provided. Our reviewer says that that 
the medical record includes a "surgery progress note", which does not include documentation of unrelated 
evaluation and management service, and therefore cannot be verified. Our reviewer found that the 
documentation does not support the billed codes. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on June 16, 2023, billed with procedure codes 
99231-24 and 99233-24.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre CGM reader. 
 
You asked the Plan to pre-approve a CGM reader. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes. 
Based on this information, we decided that Medicare rules for coverage of a CGM reader have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre CGM reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care provided on June 05, 2023. 
 
You asked the Plan to pay for the chiropractic care. You say that you are requesting reconsideration for the 
services provided. 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 chiropractic care 
provided on June 05, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J2274 and A4220 provided from November 
7, 2022, to November 30, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the denied codes cannot be reimbursed. 
 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 the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) J2274: 
 
Injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg 
 
HCPCS A4220: 
 
Refill kit for implantable infusion pump 
 
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 in terms of J2274, the physician 
order documents "morphine 40mg/ml." In this case, a more appropriate code should be reported for this 
service. J2274 should only be used for morphine sulfate that is labeled "preservative free." Morphine sulfate 
that is not labeled preservative free should be reported as J2270. 
 
In terms of A4220, the records do not contain a physician order for this item. It 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes J2274 and A4220 provided from November 7, 2022, to November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99457 and 99458 provided from August 8, 
2023, to August 25, 2023. 
 
You asked the Plan to pay for procedure codes 99457 and 99458. You say that the medical records support the 
billing of procedure codes 99457 and 99458. The Plan denied your request. The Plan says the medical records 
do not support the billing of procedure codes 99457 and 99458. 
 
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 99457 is Remote physiologic monitoring treatment 
management services, clinical staff/physician/other qualified health care professional time in a calendar month 
requiring interactive communication with the patient/caregiver during the month; first 20 minutes. The 
definition of code 99458 is Remote physiologic monitoring treatment management services, clinical 
staff/physician/other qualified health care professional time in a calendar month requiring interactive 
communication with the patient/caregiver during the month; each additional 20 minutes (List separately in 
addition to code for primary procedure). 
 
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 procedure codes 99457 and 99458. Our reviewer says that 
the medical records do not support the billing of procedure codes 99457 and 99458. Our reviewer found there 
is no evidence that remote physiological monitoring with interactive communication was performed. 
Additionally, procedure code 99458 is an add-on code and as the primary code, 99457, is not covered, the add-
on code is not covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99457 and 99458 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99457 and 99458 provided from August 8, 2023, to 
August 25, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Prolia Syringe 60mg/ml. 
 You asked the Plan to pre-approve Prolia. You say that the use of Prolia is medically necessary from your 
provider. The Plan denied your request. The Plan says you have not tried and failed treatment with one 
intravenous bisphosphonate therapy (such as zoledronic acid) to meet the criteria for Prolia.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
elements of the coverage criteria are not satisfied.  The requested service cannot be recommended. 
 Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the 
Plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from the Plan's preferred step one alternative. Therefore, the requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the use of Prolia Syringe 60mg/ml.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (E&M) services described 
by code 99213 performed on May 31, 2022. 
 
You asked the Plan to pay for 99213. You say that 99213 was a significant and separately identifiable E&M 
service unrelated to the decision to perform the minor surgical procedure and was billed with modifier -25, 
therefore it should be paid as billed. The Plan denied your request. The Plan says although billed with modifier 
-25, 99213 is denied because it was billed on the same date as a minor procedure (20610) and documentation 
does not support a significant and separately identifiable E&M service unrelated to the decision to perform the 
minor surgical procedure.  
 
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 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 99213. Our reviewer says that 99213 is not supported in the 
documentation. Our reviewer found the documentation submitted mentions only the joint pain and injection 
performed on the same day with no other medical decision making noted. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99213 have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management (E&M) services described by code 99213 performed on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service August 11, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the test was designed to detect minimum residual 
disease. The Plan denied your request. The Plan says an appropriate code was not billed. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
The file shows that a Guardant Reveal test was provided. We looked at the file and Medicare rules. The claim 
does show that a unique identifier was reported. However, the MolDX program has determined that the 
Medicare reasonable and necessary requirements have not been met for this test. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the lab testing billed for date of service August 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 26, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81238, 81240, 81241, 81291, 81306, 81328, 81335 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 26, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81238, 81240, 81241, 81291, 81306, 
81328, 81335 and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive audiometry threshold evaluation,Distortion 
product evoked otoacoustic emissions and Acoustic immittance testing provided on August 29, 2023. 
 
You asked the Plan to pay for comprehensive audiometry threshold evaluation,Distortion product evoked 
otoacoustic emissions and Acoustic immittance testing. You say that the services should be covered. 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 comprehensive 
audiometry threshold evaluation,Distortion product evoked otoacoustic emissions and Acoustic immittance 
testing provided on August 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 05, 
2023. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you thought the service would be 
fully covered. 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for the ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 the ultrasound provided on August 05, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgeries provided on May 04, 
2023, to June 05, 2023. 
 
You asked the Plan to waive the copayment for outpatient surgeries. You say that you disagree with the 
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 $350 
copayment for outpatient surgery/Medicare-coveredsurgery. 
 
You have been asked to pay a $350 copayment for outpatient surgeries. This item/service falls within the 
outpatient surgery/Medicare-coveredsurgery 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. However, since the allowed amount is less than the standard copayment, 
$174 for three dates of services and a $320.51 copayment for one date of service. The total amount you owe is 
$1,016.51 ($174 + $174 + $174 + $174 + $320.51= $1,016.51). Therefore, we decided that the Plan does not 
have to waive the copayment for outpatient surgeries provided on May 04, 2023, to June 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient and hospital inpatient provided 
on September 18, 2023, to September 21, 2023. 
 
You asked the Plan to pay for subsequent hospital inpatient and hospital inpatient. You say that this service is 
supported in the records proving medical necessity. 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 subsequent hospital 
inpatient and hospital inpatient provided on September 18, 2023, to September 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 16, 2023, to 
January 18, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says the medical 
records did not have sufficient documentation to clinically validate the diagnosis of N17.0 (acute kidney failure 
with tubular necrosis). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with N17.0 defined as acute kidney failure with tubular 
necrosis. 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 inpatient hospital services at the 
DRG originally billed. Our physician reviewer found the medical records do not document a persistent 
elevation of the patient's creatinine level above baseline despite adequate fluid repletion or prolonged 
hypotension, sepsis or nephrotoxin exposure which are the most common causes of tubular necrosis. Also, the 
records do not document a fractional excretion of sodium indicative of acute tubular necrosis. Therefore, 
diagnosis code N17.0 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 16, 2023, to January 18, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 13, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
coapyment. 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 $100 
copayment for ambulance services. 
 
You have been asked to pay a $100 copayment for ambulance services. This item/service falls within the 
ambulance 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. However, since the allowed amount is less than the standard copayment, you only owe $70. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on 
August 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on July 20, 
2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
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 outpatient surgery. 
 
You have been asked to pay a $375 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery 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 outpatient surgery 
provided on July 20, 2023.