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

 
We decided that the Plan has to pay for code G0483 for date of service June 7, 2023. 
 
You asked the Plan to pay for code G0483. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The file does not show that G0483 was previously 
billed/processed by the Plan. This means there is a lack of evidence of prior payment. Based on this 
information, we decided that Medicare rules for coverage of code G0483 have been met. Therefore, we decided 
that the Plan has to pay for code G0483 for date of service June 7, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0013M for date of service June 13, 2023. 
 
You asked the Plan to pay for procedure code 0013M. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 0013M is specifically not 
covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the services at issue were billed with 
0013M. This service is specifically not covered. Based on this information, we decided that Medicare rules for 
coverage of procedure code 0013M have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 0013M for date of service June 13, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 81479. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 81225, 81227, 81230, 81231, 81232, 
81240, 81241, 81291, 81306, 81328, 81335, and 81355.  
 
You asked the Plan to pay for procedure codes 81479, 81225, 81227, 81230, 81231, 81232, 81240, 81241, 
81291, 81306, 81328, 81335, and 81355 provided on June 15, 2023. You say that you would like the Plan to 
reconsider their denial of payment. The Plan says that the services are not covered as billed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 81479.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 81479.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
81225, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, and 81355. 
 
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 procedure codes 81225, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 
and 81355 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 services described by procedure code(s) 81225, 81227, 81230, 81231, 81232, 81240, 81241, 
81291, 81306, 81328, 81335, and 81355. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0483 for date of service March 14, 2023. 
 
You asked the Plan to pay for code G0483. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 find that CPT code G0483 is not supported in the medical record. Specifically, the submitted medical 
records did not include laboratory results for 22 or more drug classes. Based on this information, we decided 
that Medicare rules for coverage of code G0483 have not been met. Therefore, we decided that the Plan does 
not have to pay for code G0483 for date of service March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99387 provided on April 14, 2023. 
 
You asked the Plan to pay for procedure code 99387. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a new patient is a patient who has not received 
any professional services from the physician or physician group practice within the previous 3 years. 
 
In this case, you were seen by the same physician on March 29, 2023. This is not a new patient per Medicare 
rules. Therefore, we decided that the Plan does not have to pay for procedure code 99387 provided on April 14, 
2023. Please note, you are not responsible for any payment towards procedure code 99387.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient or observation care (99221) 
provided June 28, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 99221 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 straightforward or low-level medical decision making. When using total time on the date of 
the encounter for code selection, 40 minutes must be met or exceeded. 
 
CPT code 99221 (1 Unit) remains not supported. The medical records submitted do not include an initial hospital inpatient or observation care evaluation and management note for the billed date of service. Based on 
this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we 
decided that the Plan does not have to pay for initial hospital inpatient or observation care (99221) provided 
June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster vaccine (90750) provided on May 31, 2022. 
 
You asked the Plan to pay for the vaccine service. You say that you feel this should have been covered by your 
insurance. The Plan denied your request. The Plan says this is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine service. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
service. Therefore, we decided that the Plan does not have to pay for the Zoster vaccine (90750) provided on 
May 31, 2022.  
 
Benefits for the vaccine service may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 11, 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 the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
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. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 the laboratory services rendered on 
November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for date of service January 13, 
2023. 
 
You asked the Plan to pay for procedure code 99204. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says the service at issue is included in the global surgery fee 
for codes 11042 and 11045. 
 
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 99204 is: Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter. 
 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 code 99204. Our reviewer says that procedure 
code 99204 does not meet criteria for payment. Our reviewer found that the record does not support moderate 
medical-decision making. There is a more appropriate code for the level of medical decision-making provided. 
 
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 code 99204 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99204 billed for date of service January 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64415 billed for date of service May 22, 
2023. 
 
You asked the Plan to pay for procedure code 64415. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 procedure code 64415 Our reviewer says 
that procedure code 64415 does not meet criteria for payment. Our physician reviewer found that as the 
supraclavicular and axillary nerves are part of the brachial plexus, these can be considered as a single block. 
Therefore, it is not warranted to bill 2 units of code 64415.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64415 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 64415 billed for date of service May 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatric partial hospitalization. 
 
You asked the Plan to pre-approve psychiatric partial hospitalization. You say that partial hospitalization is a 
complement to your treatment and recovery to your emotional stability and quality of life. The Plan denied 
your request. The Plan says the clinical findings documented do not justify the level of care requested. 
 
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 psychiatric partial hospitalization. Our 
reviewer says that the requested psychiatric partial hospitalization.is not considered medically reasonable and 
necessary in this case. Our physician reviewer found based upon review of the records provided, you were not 
showing any dangerousness to self or others and you have not been exhibiting severe psychological or 
psychiatric impairment requiring this level of care. You were not showing any perceptual disturbance, psychosis or aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric 
care provided at the partial hospitalization level of care rather than a lower level of care as you did not have any 
suicidal or homicidal thoughts or behavioral disturbance and her symptomatology could be treated at a lower 
level of care. The health plans denial of continued partial hospitalization treatment for the dates in question 
appears appropriate. You did not appear to require partial hospitalization treatment. You were not showing any 
severity of psychological or psychiatric illness.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychiatric partial hospitalization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve psychiatric partial hospitalization.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for two units of procedure code 77002 rendered on April 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 that only 1 unit of CPT code 77002 is allowed for a single patient encounter regardless of the 
number of needle placements performed. 
 
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 77002 is "Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization 
device) (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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the record supports 2 units of 
77002; fluoroscopic guidance was provided on the right and left side. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
two units of procedure code 77002 rendered on April 10, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the follow-up visit provided on September 
11, 2023. 
 
You asked the Plan to waive the copayment for the follow-up visit. You say that the cost share is wrong. 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 $40 
copayment for Physician/Practitioner Services. 
 
You have been asked to pay a $40 copayment for the follow-up visit. This item/service falls within the 
Physician/Practitioner 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 waive the copayment for 
the follow-up visit provided on September 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an HFCWOD (E0483). 
 
You asked the Plan to pre-approve an HFCWOD. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 an HFCWOD. Our reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee does not have documented trial and failure of standard treatment or therapies to adequately mobilize 
retained secretions. There is no indication for a high-frequency chest-wall oscillation device in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an HFCWOD (E0483).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency care services provided on board a ship at sea on 
May 3, 2023. 
 
You asked the Plan to pay for emergency care. You say that you submitted the necessary documents to the 
Plan. The Plan denied your request. The Plan says proof of payment has not been submitted to support 
reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that services furnished outside of the United States 
and its territories are only covered under limited, specified circumstances. Although these services were 
furnished on board a ship, these services do not fall within Medicares coverage because the ship was not 
located in a United States port or within 6 hours of when the ship arrived at  or departed from  a United 
States port. The Plan has a supplemental worldwide coverage benefits that goes beyond Medicares coverage. 
For this reason, the Plans rules apply to this case. The Plan requires you to pay for the services up front and 
submit proof of payment to the Plan for reimbursement. 
 
We looked at the file, the Plans rules, and Medicare rules. The documentation you submitted to the Plan did 
not include proof of payment for these services. Please submit proof of payment to the Plan for consideration of 
reimbursement. Based on this information, we decided that the Plans rules for coverage of emergency care 
have not been met. Therefore, we decided that the Plan does not have to pay for emergency care services 
provided on board a ship at sea on May 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix and Epicord tissue grafts (Q4186, Q4187). 
 
You asked the Plan to pre-approve Epifix and Epicord. You say that the requested items are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested items are 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 Epifix and Epicord. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the medical documentation supports that the enrollee's surgical wound has been closing 
consistently with routine wound care, dressings and offloading. It is unclear why Epifix or Epicord skin 
substitutes are needed at this point. It appears that continuation of wound care and offloading should allow for 
continuation of the enrollee's wound to close.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epifix and Epicord have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Epifix and Epicord tissue grafts (Q4186, Q4187).