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

 
We decided that the Plan does not have to pay for eight additional units of procedure code 77300 rendered on 
May 12, 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 there was no specific rationale as to why the additional units were needed to be 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. 
 
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 records include a check box 
form that documents that the current plan would decrease coverage below a clinically acceptable level and 
would increase dose to normal tissues to above clinically acceptable levels  either of which would support an 
adaptive plan. Radiation records include treatment plan reports and records, and documentation of orders and 
electronic approval of the prescription and plan. The signed plan documents the physician approval of the 
IMRT plan and therefore the monitor unit calculations. This is sufficient to document physician involvement in 
the treatment planning process. From the treatment planning records there are 18 beams with 18 beam 
calculations. Generally, the 77300 billing code is considered to be medically necessary for each treatment 
port/gantry angle though a maximum of 10 units of 77300 (based upon recommendations by the ACR and 
ASTRO) are allowed per course. 
 
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 eight additional units of procedure code 77300 rendered on May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service April 5, 
2022.  
 
You asked the Plan to pay for procedure code 99213. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99213 is bundled into payment for code 90837. 
 
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 99213 
is a column II code to column I code 90837 with a modifier indicator of 0. The column II code is therefore not payable. 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 99213 billed for date of service April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided March 13, 2023 to March 16, 2023. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. 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. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 28, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the inpatient care have not been met. 
Therefore, we decided that the Plan does not have to pay for inpatient care provided March 13, 2023 to March 
16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73630 provided on March 9, 2023. 
 
You asked the Plan to pay for procedure code 73630. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is 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 CPT code. 
 
We find that CPT code 73630 is not supported in the medical record. Specifically, this code has a status of Q1 
and was billed on the same date of service as code 99283 which has a status indicator of "V". This code is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 
73630 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 73630 
provided on March 9, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 21, 2022 to 
October 26, 2022. 
 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 NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 21, 2022. The NOA was not received by the Plan until February 
23, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on October 21, 2022 to October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for initial hospital care (99222) provided on 
March 1, 2023. 
 
You asked the Plan to waive the copayment for initial hospital care. You say that the services at issue were a 
necessity for the enrollee's care. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $231 copayment per admission for inpatient hospital care.   
The enrollee has been asked to pay $125.06 for initial hospital care. This item/service falls within the inpatient 
hospital care benefit category. This means that the enrollee has been asked to pay less than or equal to the 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
initial hospital care (99222) provided on March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 28, 2022, billed 
with procedure codes 99100 and 76942-26. 
 
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 the billed codes is bundled into 
payment of another 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 76942-26 have not been met. In this case, we have confirmed that code 76942 is a 
column II code to column I code 36556. This claim has not been billed with an appropriate modifier to bypass 
the edit. Procedure code 99100 has a status indicator of B and is not separately payable. Therefore, we decided 
that the Plan does not have to pay for practitioner services provided on September 28, 2022, billed with 
procedure codes 99100 and 76942-26.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgery provided on February 27, 2023. 
 
You asked the Plan to waive the copayment for surgery. You say that you say that you already paid the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $245 
copayment for outpatient hospital services. 
 
You have been asked to pay a $245 copayment for surgery. This item/service falls within the outpatient 
hospital 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 surgery provided on 
February 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from February 28, 2023, to 
March 3, 2023. 
 
You asked the Plan to pay for the medication. You say that you did not ask for any special medication. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from February 28, 2023, to March 3, 2023.  
 
Benefits for the medication 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 11, 2022, 
through December 10, 2022.  
 You asked the Plan to pay for the home health services. You say that you have provided proof to show that an 
NOA was submitted on November 16, 2022.  The Plan denied your request. The Plan says the NOA was not 
received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 11, 2022. The NOA was not received by the Plan until March 
27, 2023. The documentation provided as proof of timely filing does not clearly indicate that the NOA was 
submitted and received by the health plan. Only that it was submitted and received by some entity. As more 
than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on this 
claim. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
November 11, 2022, through December 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from April 4, 2023, to May 2, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the psychotherapy was medically necessary. The 
Plan denied your request. The Plan says this provider type is not eligible to enroll in Medicare 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional 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 Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from  
April 4, 2023, to May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on March 10, 2023, to March 
24, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on March 10, 2023, to March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April 
12, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this should have been a 
follow-up appointment. 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 $45 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
specialist 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. The record shows this claim was approved and you are responsible for the 
cost share amount. Therefore, we decided that the Plan does not have to waive the copayment for the specialist 
office visit provided on April 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder Detect test (0013M) provided February 20, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that these services were medically necessary and 
therefore payable. The Plan denied your request. The Plan says this service does not meet the coverage 
requirements in the applicable Local Coverage Determination (LCD) or National Coverage Determination 
(NCD). 
 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 CxBladder Detect test (0013M) provided February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve an injection. You say that you need the requested injection. You have so 
much pain in the right knee, and you cannot walk. The Plan denied your request. The Plan says a review of the 
current medical literature does not support this service to be reasonable and necessary. More medical research 
is needed to support this is safe and effective for your condition. 
 
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 an injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have a history of chronic right knee pain due to osteoarthritis. You have been treated with 
medication, viscosupplementaiton, and previous genicular nerve radiofrequency ablation. Your provider has 
recommended a genicular nerve block. Genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but 
not limited to any of the following, degenerative joint disease; osteoarthritis of the knee; as a treatment prior to 
knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the requested genicular nerve block 
of the right knee is not medically reasonable or necessary. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a destruction by neurolytic agent, genicular nerve branches including imaging guidance, 
when performed (64624).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87481, 87798, 87491, 
87591, 87661, 87640, 87653, 87496, 87529, 87500 and 87150. We decided that the Plan does not have to pay 
for the services described by procedure code(s) 87641.  
 
You asked the Plan to pay for laboratory services provided on November 28, 2022. You say that these services 
were necessary and are supported by the medical records. The Plan says that the number of units billed exceeds 
the number allowed by Medicare. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87481, 87798, 87491, 
87591, 87661, 87640, 87653, 87496, 87529, 87500 and 87150.  
 
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) 87481, 87798, 87491, 87591, 
87661, 87640, 87653, 87496, 87529, 87500 and 87150.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
87641. 
 
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 87641 is 1. The MAI value for this code is 3. You billed 2 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 the services described by procedure code(s) 87641 have not been met. Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
87641. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided June 
18, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you believe these services were 
medically necessary. The Plan denied your request. The Plan says the documentation requirements have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, there is no face-to-face encounter. The delivery 
ticket documentation submitted is not clear if the DME was delivered to the patient or if the patient received 
the DME devices in the office and the dates on the delivery ticket are contradicting as well. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided June 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 16, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary.  
The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible 
and available and requires authorization for certain services. No medical necessity for an out-of-network 
provider such as an urgent or an emergent situation that has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on March 16, 2023.