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

 
We decided that the Plan does not have to pay for the genetic testing provided on March 14, 2023, billed with 
codes 81238, 81226, 81225, 81306, 81328, 81335, 81231, 81227, 81232, 81241, 81291, and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that the treatment sought was medically 
necessary. 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. The file shows that a combined cardio and pharmacogenomics panel test was provided. We looked at the file 
and Medicare rules. This NGS panel was not billed with a single 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 March 14, 2023, billed with 
codes 81238, 81226, 81225, 81306, 81328, 81335, 81231, 81227, 81232, 81241, 81291, and 81240.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the SNF PPS rate. 
 
The Plan must follow Medicare rules. Medicare rules say that under skilled nursing facility (SNF) prospective 
payment system (PPS) all Medicare covered Part A services that are considered within the scope or capability 
of SNFs are considered paid in the PPS rate.  
 
We looked at the file and Medicare rules. Payment for the requested services in this case is included in the SNF 
PPS rate. The services are not separately payable. 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 
services provided on October 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that without the Botox shots you cannot eat, and you would 
like your request for treatment to be reconsidered. The Plan denied your request. The Plan says this request 
does not meet the definition of the 'Incident To' requirements, as it is not being furnished by a physician. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99309 performed on May 9, 2023. 
 You asked the Plan to pay for 99309. You say that 99309 should be paid as billed because it is supported in the 
documentation and was billed for an inpatient physician. The Plan denied your request. The Plan says 99309 is 
denied because the wrong POS was 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. The rules also say nursing facility services codes 
shall be used with POS 31, 32, 54, and 56. 
 
In this case, the CPT Code Manual definition of code 99309 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using total time on the date of the encounter for code 
selection, 30 minutes must be met or exceeded. 
 
We find that CPT code 99309 is not supported in the medical record. Specifically, we confirmed that 99309 is a 
nursing facility services code. In this case 99309 was billed with POS 13, indicating an assisted living facility. 
According to Medicare rules, POS 13 is not listed as an appropriate POS when billing nursing facility services 
codes such as 99309. Based on this information, we decided that Medicare rules for coverage of 99309 have 
not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management 
services described by code 99309 performed on May 9, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service May 8, 2023. 
 
You asked the Plan to pay for the billed services. You say that the lab service should be covered. The Plan 
denied your request. The Plan says that the testing is a non-covered service. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the lab services by a contract provider. The file does not show that the Plan provided 
notice that the billed services would not be covered. Under Medicare rules, this means the billed services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab testing billed for 
date of service May 8, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant removal (D6100), and a bone replacement graft 
(D7953) provided on March 23, 2023. 
 
You asked the Plan to pay for D6100 and D7953. You say that these services should be covered. The Plan 
denied your request. The Plan says the denied dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
implant removal (D6100), and a bone replacement graft (D7953) provided on March 23, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C. 
 
You asked the Plan to pre-approve Gamunex-C. The Plan denied your request. The Plan says medical necessity 
was not able to be established with the information provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Gamunex-C. Our reviewer says that 
Gamunex-C is not medically reasonable and necessary. Our physician reviewer found the reviewed 
documentation indicates that the clinical note received did not mention initiation of Gamunex-C or reason is 
not requiring treatment with it at this time. Our reviewer found that its use is not supported by one of the major 
drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) 
approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gamunex-C have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gamunex-C.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 13, 2023, to March 
14, 2023, billed with evaluation and management (EM) codes 99291 and 99233. 
 
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 that 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 99291 and 99233 is critical care, evaluation and 
management of the critically ill or critically injured patient; first 30-74 minutes, and subsequent hospital 
inpatient or observation care, per day, for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the enrollee didn't appear to require 
critical care based on the documentation provided, making the code 99291 not justified. Also, the code, 99233 
was not justified as the documentation did not support a high level of medical decision making or a 50+ 
duration of the encounter.  
 
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 13, 2023, to March 14, 2023, billed 
with evaluation and management (EM) codes 99291 and 99233.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81456) provided on January 20, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and should be paid. 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 (81456) provided on January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 8, 2023. 
 
You asked the Plan to pay for OIVIT services. 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. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (82075, 99214) provided on October 4, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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 82075 is "Alcohol (ethanol); breath". The CPT Code 
Manual definition of code 99214 is "Office or other outpatient visit for the evaluation and management of an 
established patient, which requires a medically appropriate history and/or examination and moderate level of 
medical decision making. When using time for code selection, 30-39 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 the services. Our reviewer says that the use of codes 82075 
and 99214 is not supported by the records provided. Our reviewer found that for code 82075, the procedure 
report does not include documentation of breath alcohol. Oral fluid definitive is described in procedure report. 
There is a more appropriate code that would be reported for the service documented. For code 99214, the 
procedure report supports a medically appropriate history and examination, however moderate level of 
decision-making is not supported. 
 
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 the services (82075, 99214) provided on October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service May 20, 
2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the billed code 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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making.  
 We find that CPT code 99223 is not supported in the medical record. The records show that the enrollee 
presented to the hospital after vomiting at home. The enrollee was in no acute distress. He was treated with 
antiemetics. The records do not show that a high level of medical decision making was provided. 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 procedure code 99223 billed for date of service May 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the third level facet injection provided on May 10, 2023. 
 
You asked the Plan to pay for the injection. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the need for a three or four-level procedure bilaterally 
may be considered under unique circumstances and with sufficient documentation of medical necessity on 
appeal. 
 
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 injection. Our reviewer says that the 
requested facet injection is not medically reasonable and necessary. Our physician reviewer found that there is 
no documentation of a clinically unique circumstance for consideration of treatment at more than 2 levels. The requested 3rd level facet injection is not medically reasonable or necessary according to the LCD coverage 
criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pay for the third level facet injection provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99232) provided from May 22, 2023, to May 
24, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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 99232 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded". 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 99232 is 
not supported by the records provided. Our reviewer found that the documentation supports an appropriate 
exam, but not an appropriate history or medical decision-making of moderate complexity from May 22, 2023, 
to May 24, 2023, so code 99232 is not appropriate. 
 
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 the services (99232) provided from May 22, 2023, to May 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73630-26-LT billed for date of service 
December 6, 2022. 
 
You asked the Plan to pay for the billed service. You say that a required modifier was added, and a corrected 
claim was submitted. The Plan denied your request. The Plan says 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.  
 
We looked at the file and Medicare rules. The file shows that the billed code was reimbursed by the Plan on 
May 21, 2023. A comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed services were provided twice on the same date. The medical records 
submitted were not for the date of service at issue.  Based on this information, we decided that the Medicare rules for the billed service have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 73630-26-LT billed for date of 
service December 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuation of inpatient mental health services provided 
from January 30, 2023, to February 27, 2023. 
 
You asked the Plan to pay for the continuation of inpatient mental health services. You say that the medical 
records provided support the services in dispute. The Plan denied your request. The Plan says the enrollee did 
not have a health problem that needed this level of care on the dates of service in dispute. The Plan says that the 
enrollee could have safely been treated at a lower level of care. 
 
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 continuation of inpatient mental health 
services. Our reviewer says that the inpatient mental health services in dispute are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee was compliant with treatment 
while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question as she did not have dangerousness to self or others and was compliant with her treatment. This 
enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a 
danger to herself or others and does not have auditory or visual hallucinations. It does not appear that active 
treatment was taking place beyond the date in question. It does not appear that the services were reasonably 
expected to improve the enrollees condition or for the purpose of diagnosis beyond the date in question. 
 
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 continuation of inpatient mental health services have not been met. 
Therefore, we decided that the Plan does not have to pay for a continuation of inpatient mental health services 
provided from January 30, 2023, to February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on April 24, 2023. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the testing is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the drug testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided documentation does not describe the enrollee needing 27 drug classes tested. There is no evidence of the enrollee taking most of the tested drug classes or evidence of drug abuse/misuse. There are 
no abnormal drug screening results to indicate a need for this comprehensive of a definitive drug testing order. 
 
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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing provided on April 24, 2023.