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

 
We decided that the Plan does not have to pay for radiological services provided on August 19, 2022, billed 
with procedure codes 70100, 70360, 71045, 72040, 74230, 74240 and 99203. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The service provided is a barium swallow study 
and includes the administration of a substance to the patient. As such, this is a non-covered service. Therefore, 
we decided that the Plan does not have to pay for radiological services provided on August 19, 2022, billed 
with procedure codes 70100, 70360, 71045, 72040, 74230, 74240 and 99203.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 25, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that your benefits clearly state you are responsible 
for only 30% for outpatient mental health counseling for out-of-network providers. The Plan denied your 
request. The Plan says the provider type is not eligible to participate in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
18, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound debridement (97598) provided on May 25, 2023. 
  You asked the Plan to pay for wound debridement (97598). You say that the services were medically necessary 
to restore the enrollee's functional abilities and the claim should be reprocessed for payment. The Plan denied 
your request. The Plan says procedure code 97598 was billed without an appropriate primary code. 
 
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 97598 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for wound debridement (97598) provided on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99458 billed for date of service February 27, 
2023.   
You asked the Plan to pay for procedure code 99458. 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 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 99458 is 3. The MAI value for this code is 3. You billed 5 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99458 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99458 billed for date of service February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 lab services provided on November 2, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 30, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the patient was not enrolled in hospice. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 12, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided on March 30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95999 billed for July 1, 2022. 
 
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 procedure code 95999 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 95999 is unlisted neurological or neuromuscular 
diagnostic procedure. 
 
We find that CPT code 95999 is not supported in the medical record. Specifically, the file shows that Train of 
Four testing was performed and there is a more appropriate code for these services. Based on this information, 
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 95999 billed for July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on September 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. 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 lab services (81479) provided on September 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 24, 2023. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that HHAs must submit HH PPS claims with the 4th 
digit of 9. 
 
We looked at the file and Medicare rules. The claim was submitted with type of bill 323. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided on March 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that the test was medically necessary. 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect test (0012M) provided February 7, 
2023. 
 
You asked the Plan to pay for the laboratory service. You say that you request review and authorization of 
coverage for the Cxbladder Detect test for the enrollee. The Plan denied your request. The Plan says the CX 
Bladder panel remains unproven at this time.  
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at 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 Cxbladder Detect test (0012M) provided February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gym equipment rentals for fitness class instruction purchased 
in the 2022 calendar year. 
 
You asked the Plan to pay for gym equipment rentals. You say that you should have these fees covered as you 
are a fitness instructor. You would like to not be held to the letter of your contract or to have the wellness 
benefit changed in the future, as you feel your dedication to your health should be considered and rewarded. 
The Plan denied your request. The Plan says these services are not eligible for reimbursement under your 
supplemental wellness benefit, and you were already given a one-time exception and educational letter for 
these services in 2021. 
 The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when they are the items/services specified in the contract. 
 
The Plans rules for coverage of gym benefits have not been met because gym equipment rentals for fitness 
class instruction are not among those items/services detailed for coverage in the contract. Therefore, we 
decided that the Plan does not have to pay for gym equipment rentals for fitness class instruction purchased in 
the 2022 calendar year.  
 
Your complaint about the coverage specifics of the Plans supplemental benefit is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Prometheus IBD sgi Diagnostic test (81479, 82397) provided 
December 2, 2021.  
 
You asked the Plan to pay for the laboratory service. You say that you are a proprietary laboratory and are not 
patient facing. You do not have access to patients and physician's office notes or medical records. The Plan 
denied your request. The Plan says Prometheus IBD sgi Diagnostic test is non-covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at 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 Prometheus IBD sgi Diagnostic test (81479, 82397) provided December 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) rendered on 
February 21, 2023. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not 
used in clinical management exceeds the needs of the enrollee.  
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records not show screening test results which are positive or inconsistent with prescription 
medications, dosing schedules, or history and expected results. The condition of the enrollee did not meet the 
Medicare rules for approval of definitive urine drug testing (UDT) for 22 or more drug classes. The review has 
determined that the records did not support a need for 22+ drug classes being tested. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for drug testing services (procedure code G0483) rendered on February 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued inpatient psychiatric hospitalization. 
 
You asked the Plan to pre-approve the services. 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. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that it appears that 
the enrollee has reached maximum benefit from his inpatient psychiatric stay.  The enrollee is noted to be in no 
psychiatric distress and is eating and sleeping adequately. The enrollee is complaint with medications. The 
progress notes do not indicate that the enrollee has been aggressive with peers or staff on the unit or has had 
any recent attempt to harm himself during the disputed period.  As of the last covered day, there is no 
indication in the available medical records that the enrollees psychiatric symptoms could not be managed on a 
less restrictive basis. As of the last covered day the enrollee did not express any active suicidal ideation or 
intent, or any intent to harm themselves or anyone else. The enrollee was not exhibiting any other significant 
symptoms such as psychosis or mania. The enrollee had no acute psychiatric issues that would require 
continued inpatient care beyond 08/11/2023. The enrollee has chronic symptoms. The available medical 
records do not support that continued inpatient care will change these symptoms or the enrollees current 
condition. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continued inpatient psychiatric hospitalization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 23, 2023, billed with 
procedure codes s 96365-59, 96366-59 (x2), and 96521. 
 
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, the CPT Code Manual definition of codes 96365-59, 96366-59 (x2), and 96521 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional hour, and refilling and 
maintenance of portable 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that in this case, there is a more 
appropriate procedure code to report for the service provided. Also, the medical record includes a physician 
order for refilling and maintenance of portable pump, however procedure was documented in the medical 
record. 
 
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 March 23, 2023, billed with procedure codes 
s 96365-59, 96366-59 (x2), and 96521.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Assay testing (81455) provided on March 1, 
2023. 
 
You asked the Plan to pay for the Tempus xT Assay testing. You say that this testing is medically necessary. 
The Plan denied your request. The Plan says under Medicare guidelines, the request is not medically necessary 
because your records show you do not have recurrent, relapsed, refractory, metastatic, or advanced stage III or 
IV cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS panels may be covered when the enrollee 
has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus xT Assay testing have not been met. Specifically, the documentation does not support 
that the enrollee has recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Therefore, 
we decided that the Plan does not have to pay for the Tempus xT Assay testing (81455) provided on March 1, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Assay testing (81455) provided on March 7, 
2023. 
 
You asked the Plan to pay for the Tempus xT Assay testing. You say that this testing is medically necessary. 
The Plan denied your request. The Plan says under Medicare guidelines, the request is not medically necessary 
because your records show you do not have recurrent or advanced stage cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS panels may be covered when the enrollee 
has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus xT Assay testing have not been met. Specifically, the documentation does not support 
that the enrollee has recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Therefore, 
we decided that the Plan does not have to pay for the Tempus xT Assay testing (81455) provided on March 7, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) device 
(E0730) provided February 22, 2023. 
 
You asked the Plan to pay for the TENS device. You say that please review the attached documents and 
reprocess this claim.  The Plan denied your request. The Plan says TENS therapy for Chronic Low Back Pain 
(CLBP) is 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 looked at the file, and Medicare rules. The records show that the chief complaint was chronic low back 
pain involving the lumbar spine. Based on this information, we decided that Medicare rules for coverage of the 
TENS device have not been met. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulator (TENS) device (E0730) provided February 22, 2023.