Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483). 
 You asked the Plan to pre-approve the injection. You say that you have bad lower back pain, and the procedure 
is to see if they can release the pain. The Plan denied your request. The Plan says the enrollee does not meet the 
LCD criteria for coverage. 
 
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 injection. Our physician reviewer 
found the LCD requires radicular symptoms to be clearly documented and to correspond to imaging. This is not 
clearly documented; therefore, the request is deemed not medically reasonable and 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging 
guidance (fluoroscopy or CT), lumbar or sacral, single level (64483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service June 5, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 procedure code 99233 have been met. 
Specifically, evaluation and management records for the date of service at issue have not been provided to 
corroborate the procedure code billed. Therefore, we decided that the Plan does not have to pay for procedure 
code 99233 billed for date of service June 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 11, 2023. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87506) provide don January 10, 2023. 
 
You asked the Plan to pay for the lab 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 87506 is "Infectious agent detection by nucleic acid 
(DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, 
Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, 
multiple types or subtypes, 6-11 targets". 
 
We find that CPT code 87506 is not supported in the medical record. Specifically, the provided lab report shows that 26 pathogens were tested. The records do not show that 6-11 targets were tested in this case, as 
required by code 87506. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
(87506) provide don January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0326U billed for February 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 procedure code 0326U 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 0326U is targeted genomic sequence analysis panel, solid 
organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, 
gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0326U is not supported in the medical record. Specifically, there is no documentation 
of a targeted genomic sequence panel with cell-free circulating DNA analysis of 83 or more genes. 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 0326U billed for February 28, 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 March 9, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that this should be paid for. The Plan denied your 
request. The Plan says the records do not support the services billed. 
 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 March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99211 billed for date of service January 5, 
2022.   
You asked the Plan to pay for procedure code 99211. You say that you disagree with the Plan's 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 99211 is 1. The MAI value for this code is 3. You billed 1 unit of this code 
on two separate claims, 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 99211 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99211 billed for date of service 
January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 21, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says insufficient information was provided to review this claim. 
 
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 laboratory services have been met. 
Specifically, no medical records or literature was provided to support the service at issue. Only lab results were 
submitted. No office or clinical notes were provided to support medical necessity of this service. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the $30 copayment for the eye exam. We decided that the Plan does not 
have to waive the $15 copayment for the eye exam.  
 You asked the Plan to waive the copayment for your eye exam on April 4, 2023. You say that you initially 
received an Explanation of Benefits (EOB) that did not have a co-pay listed. The Plan says that this cost 
sharing was charged correctly. 
 
We decided that the Plan has to waive the $30 copayment for the eye exam.  
 
The rules say that a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information. 
Your contract with the Plan says that enrollees must pay a $15 copayment for each routine eye exam. 
 
The Plan says you must pay a $30 copayment for each routine eye exam. Based on the Plan contract, however, 
you cannot be asked to pay more than a $15 copayment for a routine eye exam. Therefore, we decided that the 
Plan has to waive the $30 copayment which was applied to the eye exam.  
 
We also decided that the Plan does not have to waive the $15 copayment for the eye exam. 
 
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 $15 for 
a routine eye exam. Therefore, we decided that the Plan does not have to waive the $15 copayment for the eye 
exam. 
 
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 pay for the services (28270, 28232) provided on January 18, 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 28270 is "Capsulotomy; metatarsophalangeal joint, with 
or without tenorrhaphy, each joint (separate procedure)". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 28270 is 
not supported by the records provided. Our reviewer found that the medical records provided do not include 
sufficient documentation to validate a "Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, 
each joint (separate procedure)", was performed on January 18, 2023. Therefore, this procedure cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 28270 have not been met. 
 
In this case, we have also confirmed that code 28232 is a column II code to column I code 28270. 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 the services 
(28270, 28232) provided on January 18, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service December 6, 
2021. 
 
You asked the Plan to pay for procedure code 95941. You say that this code documents continuous 
intraoperative monitoring and should be paid. 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 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95941 billed for date of service December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on February 13, 2023, billed 
with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on February 13, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 
87500.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection (20611) and 
ultrasound (76881) provided on March 24, 2021. 
 You asked the Plan to pay for arthrocentesis and ultrasound. You say that medical records submitted supports 
codes 20611 and 76881 and should be paid. The Plan denied your request. The Plan says Current Procedural 
Terminology (CPT) code 20611 (2 units) remains not supported. The Plan says that this code represents 
arthrocentesis, aspiration and/or injection, with ultrasound guidance, with permanent recording and reporting. 
However, the Plan say that the records submitted didn't include documentation of permanently recorded 
images.  
 
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 CPT Code Manual definition of code 20611 is arthrocentesis, aspiration and/or injection, major joint or 
bursa (eg, shoulder, hip, knee, subacromial bursa), with ultrasound guidance, with permanent recording and 
reporting. We find that code 20661 is not supported in the medical records. Specifically, there is no 
documentation confirming permanent recording and reporting of the images. 
 
In addition, we have confirmed that code 76881 is a Column 2 code in relation to Column 1 code 20661. 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 
arthrocentesis, aspiration and/or injection (20611) and ultrasound (76881) provided on March 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on March 16, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB code. Therefore, we decided that the Plan does not have to pay for the home health services rendered on 
March 16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285-25) provided on April 16, 
2023. 
 
You asked the Plan to pay for an emergency room visit. You say that this was not a duplicate. The Plan denied 
your request. The Plan says this is a duplicate to a previously billed emergency room service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that Current Procedural 
Terminology (CPT) modifier -25 should only be used on claims for evaluation and management (E/M) 
services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service. Both the medically 
necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician 
or qualified nonphysician practitioner in the patients medical record to support the claim for these services. 
 
We looked at the file and Medicare rules. While the service at issue was billed with modifier -25 to 
differentiate it from the other emergency room visit billed on this date of service, the submitted records do not 
document both the previously billed visit and the visit at issue to support the claim. Based on this information, 
we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we 
decided that the Plan does not have to pay for an emergency room visit (99285-25) provided on April 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service May 8, 2023.  You asked the Plan to pay for procedure code 88341. You say that these services were supported as billed. 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 88341 is 13. The MAI value for this code is 3. You billed 14 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service May 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84481 and 82607 billed for date of service 
March 15, 2022.  
 You asked the Plan to pay for procedure codes 84481 and 82607. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 84481 and 82607 is 1. The MAI value for this code is 2. You billed 2 
units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 84481 and 82607 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 84481 and 82607 billed for date of service March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (64493) and second level (64494). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is in severe pain, and he has had 
injections in the past which have helped with pain. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 service. Our physician reviewer 
found you have radicular symptoms and degenerative disc changes. The LCD requires no other probable pain 
generator. There are other probable pain generators. Therefore, the request is deemed not medically reasonable 
and 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint 
(or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 
(64493) and second level (64494).