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

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service March 1, 
2023.  
 
You asked the Plan to pay for procedure code 87798. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 19 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service March 1, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound guidance for vascular access requiring 
ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time 
ultrasound visualization of vascular needle entry, with permanent recording and reporting (76937) provided on 
April 13, 2023. 
 
You asked the Plan to pay for the ultrasound. You say that the medical records submitted supports code 76937 
and should be paid. The Plan denied your request. The Plan says code 76937 requires ultrasound evaluation of 
potential access sites; documentation of selected vessel patency; concurrent real-time ultrasound visualization of vascular needle entry; and permanent recording and reporting. However, the records didn't include 
documentation of selected vessel patency; concurrent real-time ultrasound visualization of vascular needle 
entry. 
 
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 76937 is the ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites. 
 
We find that CPT code 76937-26 is not supported in the medical record. Specifically, the documents submitted 
does not support code 76937. Based on this information, we decided that Medicare rules for coverage of the 
ultrasound (76937) have not been met. Therefore, we decided that the Plan does not have to pay for the 
ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (76937) provided on April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service February 27, 
2023.  
 
You asked the Plan to pay for procedure code 87798. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 19 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service February 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from December 16, 2022, to January 14, 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 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 December 16, 2022. The NOA was not received by the Plan. 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 rendered from December 16, 2022, to January 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urologic services. 
 
You asked the Plan to pay for urologic services. You say that you would like to see another provider because 
he was your surgeon and did all the follow-ups after the surgery.  The Plan denied your request. The Plan says 
the services were not urgent or emergent and could have been rendered by an in-network provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 urologic services. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the services were not urgent or emergent and 
could have been rendered by an in-network provider. You are not currently receiving any active treatment 
and/or medical management of your condition that makes it medically necessary for you to continue care with 
the out-of-network urology provider as requested. The health plan has shown that they have in-network urology 
specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care 
required for treatment of your condition. The records show that your medical management and/or follow-up 
care can be safely transitioned to an in-network urology specialist 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 urologic services have not been met. Therefore, we decided that the Plan does 
not have to pay for urologic services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76937 provided on December 17, 2022. 
 
You asked the Plan to pay for procedure code 76937. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the records do not support the service 
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. In this case, the CPT Code Manual definition of 
code 76937 is Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure). 
 
We find that CPT code 76937 is supported in the medical record. Specifically, the records show that ultrasound 
guidance for vascular access was used for the procedure. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76937 have been met. Therefore, we decided that the Plan has to pay for 
procedure code 76937 provided on December 17, 2022.  
 
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 the lipid panel (80061) provided on April 18, 2023. 
 
You asked the Plan to pay for the lipid panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says screening services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the lipid panel, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
lipid panel (80061) provided on April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for October 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0483 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 G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not list specifically what test(s) were to be performed. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0483 billed for October 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307, G0480, and 83789 billed for April 5, 
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 procedure codes 80307, G0480, and 83789 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 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service. 
 
We find that CPT code 80307 is not supported in the medical record. Specifically, presumptive drug testing 
was previously paid for this enrollee for the same date of service. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met.  
 
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 
83789 and G0480 are column II codes to column I code 80307. This claim has not been billed with an 
appropriate modifier to bypass the edit. The -59 modifier is not supported as a separate and 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 codes 80307, G0480, and 83789 billed 
for April 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided on January 14, 2023, to January 
31, 2023, by an OON provider.  
 
You asked the Plan to pay for home health care. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 home health care provided on January 14, 2023, to January 31, 
2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for two units of procedure code 84520 rendered on March 28, 
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 the provider has not documented any medical necessity for performing the extra unit. 
 
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 84520 is 1. The MAI value for this code is 3. You billed 2 units of this code, exceeding the MUE.  
 
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 [insert code at issue]. Our reviewer says that 
the services at issue in this case are not supported by the medical records. Our reviewer found that the 
documentation does not justify the repeat testing.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of [insert code at issue] have not been met. Therefore, we decided that the Plan 
does not have to pay for two units of procedure code 84520 rendered on March 28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 20, 2022, 
through December 26, 2022.  
 
You asked the Plan to pay for the home health services. You say that the services provided were medically 
necessary.  The Plan denied your request. The Plan says this was not billed correctly.   

The Plan must follow Medicare rules. Medicare rules say that home health services must be submitted on an 
institutional claim. 
 
We looked at the file and Medicare rules. The services at issue were submitted on a professional claim, which 
is not appropriate for Medicare home health billing. Based on this information, we decided that Medicare rules 
for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have 
to pay for the home health services provided from October 20, 2022, through December 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of lateral exostosis (D7471), the removal of 
torus mandibularis (D7473), the deep sedation (D9222 and D9223), the medicaments (D9630), and the 
unspecified adjunctive procedure (D9999) provided on April 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental services were for a necessary medical 
surgery to correct bone growth which was causing you mouth pain. The Plan denied your request. The Plan 
says the denial of payment for these services is correct, because they are not covered by the Plan or by 
Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the removal of lateral exostosis 
(D7471), the removal of torus mandibularis (D7473), the deep sedation (D9222 and D9223), the medicaments 
(D9630), and the unspecified adjunctive procedure (D9999) provided on April 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says Keytruda is not 
medically necessary.  
 
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 the drug. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found that the requested use of Keytruda is not 
FDA-approved. Keytruda is also not supported by one of the major drug compendia or by clinical research. 
 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraorifice barrier (D3911) for tooth #8 and #9 provided 
on May 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services and 
would like the Plan to pay for them. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the intraorifice barrier is not covered by the Plan. 
 
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 the 
intraorifice barrier (D3911) for tooth #8 and #9 provided on May 26, 2023.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Feraheme. 
 
You asked the Plan to pre-approve the drug. You say that Feraheme is not medically necessary. The Plan 
denied your request. The Plan says that the step therapy requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. If a Plan decides to apply step therapy requirements to Part B drugs, they must 
disclose that information in the ANOC and EOC documents. The Plan's contract does not indicate that it has 
implemented such criteria for certain Part B medications. 
 
We looked at your contract with the Plan. We did not see where the contract says that the Plan has decided to 
apply step therapy requirements to Part B drugs. This means that the Plan did not follow Medicare rules for 
disclosure of step therapy information. Therefore, we decided that the Plan has to pre-approve Feraheme.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialty intraocular lens (IOL). 
 
You asked the Plan to pre-approve a specialty IOL. You say that this is only for your right eye. The Plan denied 
your request. The Plan says coverage of a specialty lens following cataract surgery is beyond what Medicare 
covers for cataract removal or for insertion of a conventional intraocular lens and is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the astigmatism-correcting functionality of an 
IOL does not fall into the benefit category and is not covered. Therefore, we decided that the Plan does not 
have to pre-approve a specialty intraocular lens (IOL).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that this service is appropriate 
and medically necessary. The Plan denied your request. The Plan says the requested service is not covered by 
Medicare or the health plan. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the record indicates that the enrollee has squamous cell carcinoma of 
the skin. There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the 
requested service. Our reviewer found that the record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. Our physician reviewer also found that the requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350) provided on 
April 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 4, 2023. Therefore, 
we decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350) provided on 
April 4, 2023.