Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on April 25, 2023. 
 
You asked the Plan to waive the copayment for CT scan. You say that you were under the impression it would 
be around $25. You wont be able to afford the $159.21 copay. 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 $180 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $180 copayment for CT scan. 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. However, since the allowed amount is less than the standard 
copayment, you only owe $159.21. Therefore, we decided that the Plan does not have to waive the copayment 
for CT scan provided on April 25, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64450-59 billed for date of service December 
7, 2022. 
 
You asked the Plan to pay for procedure code 64450-59. You say that the service was for post operative pain 
management. The Plan denied your request. The Plan says payment for code 64450-59 is bundled into payment 
for code 01402. 
 
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 64450-is a column II code to column I code 01402. The medical 
records provided do not show that the service billed with the -59 modifier was a distinct procedural service.  
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 64450-59 billed for date of service December 7, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for date of service February 14, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that Original 
Medicare is responsible for coverage. 
 
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 looked at the file and the rules. Hospice related claims begin the date of the hospice election. In this case, 
hospice election began on February 21, 2023. The enrollee was not under hospice at the time the service at 
issue were provided. Based on this information, we decided that Medicare rules for coverage of the billed 
services have been met. Therefore, we decided that the Plan has to pay for the home health care billed for date 
of service February 14, 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 pay for the electrical stimulation services (G0283) provided 
September 22, 2022.  
 
You asked the Plan to pay for the electrical stimulation services . You say that please review the medical record 
and process the claim after review. The Plan denied your request. The Plan says this service is considered 
investigational and is not eligible for coverage. 
 
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 electrical stimulation services have not been met. Therefore, we decided that the Plan does not 
have to pay for the electrical stimulation services (G0283) provided September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 27, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect date of service. 
 
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 find that payment for CPT code 81518 is not supported in the medical record. Specifically, the claim was 
billed with the incorrect date of service. The records show that the specimen was collected on August 21, 2018. 
The date the specimen was collected should be used as the date of service. 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 the lab services provided on March 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 12, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have billed the services at issue correctly. 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 March 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on April 28, 2023. 
 
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 services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that home health claims must report a 0023 revenue code 
line on which the first four positions of the HIPPS code match the code submitted on the RAP. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 0023 
revenue code or correct HIPPS code. 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 home health 
services rendered on April 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99306 billed for date of service February 15, 
2023. 
 
You asked the Plan to pay for procedure code 99306. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says the service provided would be more 
accurately reported with a different CPT 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, the CPT Code Manual definition of code 93306 is echocardiography, transthoracic, real-time with 
image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler 
echocardiography, and with color flow Doppler echocardiography. 
 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 99306. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the procedure report describes a limited 
Echocardiography, for which there is a more specific code to report. 
 
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 99306 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99306 billed for date of service February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81518 for date of service May 1, 2023. 
 
You asked the Plan to pay for procedure code 81518. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81518 is not payable as billed. Specifically, the medical records submitted include a test 
result for the billed test with a report date of May 1, 2023; however, the records indicate that the date of 
specimen collection was on December 18, 2018. The date of service of the test/service must be the date the 
specimen was collected; therefore, this service cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure code 81518 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 81518 for date of service May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 8, 2023, billed 
with procedure code 99212-25. 
 
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 payment for this service is included in the global 
fee for code 20610. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, the Plan denied the services as global to procedure code 20610. Documentation 
provided does not include an Explanation of Claims payments to verify the referenced claim in which 20610 
was paid. Therefore, we decided that the Plan does not have to pay for practitioner services provided on 
February 8, 2023, billed with procedure code 99212-25.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you would like to continue services and the appeal 
processed as soon as possible because the facility is trying to kick you out. The Plan denied your request. The 
Plan says the documentation does not support that you are making progress in your function and does not show 
that you are is willing or able to do therapy for 2 hours per day, 7 days per week. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 billed for date of 
service February 10, 2023. 
 You asked the Plan to pay for procedure codes 87481, 87653, and 87798. The Plan denied your request. The 
Plan says payment for codes 87481, 87653, and 87798 is bundled into payment for code 87801. 
 
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 
87481, 87653, and 87798 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 
billed for date of service February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 for date of service 
November 18, 2022. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. 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. 
 
We find that CPT codes 83520 and 87798 are not supported in the medical record. Specifically, these codes 
represent a not otherwise specified code. However, a complete description of the not otherwise specified code 
was not included. The order/ lab requisition must include what laboratory test was ordered/requested in order to 
validate the not otherwise specified code billed. Therefore, the billed codes and units cannot be verified. Based 
on this information, we decided that Medicare rules for coverage of procedure codes 83520 and 87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 83520 and 87798 for 
date of service November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic procedure (97110), occupational therapy 
evaluation (97165), therapeutic activities (97530) and self-care/home management training (97535) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve occupational therapy services. You say that the enrollee is requesting this 
facility for occupational therapy. The Plan denied your request. The Plan says the requested provider is not 
contracted in the enrollees network. There are in-network providers available for this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a therapeutic procedure (97110), occupational therapy evaluation (97165), therapeutic activities (97530) and 
self-care/home management training (97535) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0998 billed for date of service April 22, 
2023. 
 
You asked the Plan to pay for procedure code A0998. 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 A0998 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A0998 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code A0998 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A0998 billed for date of service April 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and accessory provided 
on March 15, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and accessory. The Plan denied your request. 
The Plan says this is not payable for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device and accessory provided on March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve to CGM. You say that the items should be covered as the enrollee disagrees 
with the denial. The Plan denied your request. The Plan says the items denied correctly as the enrollee does not 
meet the clinical requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 to CGM. Our physician reviewer found 
that the enrollee does not meet the clinical requirements to be approved, there is no record that the enrollee is 
taking insulin or has a history of hypoglycemia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of to CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223 x3 units) provided June 7, 2022, 
through June 12, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are 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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs.  
 Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside 
and on the patient's hospital floor or unit. 
 
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 services Our reviewer found the 
documentation supports a comprehensive exam and decision making of high complexity, but not a 
comprehensive history. 
 
We looked at this physician reviewers 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 initial hospital care (99223 x3 units) provided June 7, 2022, through June 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin and Pemetrexed. 
 
You asked the Plan to pre-approve Carboplatin and Pemetrexed. You say that the medications are medically 
necessary for the enrollee's treatment to improve their current symptoms. The Plan denied your request. The 
Plan says this mix of drugs for the enrollee's cancer is not supported by the health plan. 
 
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 Carboplatin and Pemetrexed. Our 
reviewer says that the medications are not medically necessary. Our physician reviewer found the enrollee has 
progressed on Tagrisso. The requested use of Carboplatin and Pemetrexed cannot be recommended for the 
enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Carboplatin and Pemetrexed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Carboplatin and Pemetrexed.