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

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service June 15, 
2023. 
 You asked the Plan to pay for procedure code 71045. You say that 71045 should be paid as billed because it 
was reported correctly and is supported in the medical records. The Plan denied your request. The Plan says 
payment for code 71045 is bundled into payment for code 71046. 
 
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 71045 
is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71045 billed for date of service June 15, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dual-energy x-ray absorptiometry (DXA) of the axial 
skeleton (77080) and dual-energy x-ray absorptiometry (DXA) of the appendicular skeleton (77081) provided 
on March 15, 2022. 
 
You asked the Plan to pay for the DXAs. You say that you would like to dispute all of the debt because it is not 
your fault your doctor ordered this bone scan. You also say that you do not want to be charged for this bill. The 
Plan denied your request. The Plan says you had a bone scan done earlier than 23 months from the last scan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for a screening BMM once every 
2 years.  
 
 
 
 We looked at the file and Medicare rules. Specifically, the record shows that you last received a BMM on 
September 24, 2020, which was less than 2 years from to the DXAs provided on March 15, 2022. Based on this 
information, we decided that Medicare rules for coverage of the DXAs have not been met. Therefore, we 
decided that the Plan does not have to pay for the dual-energy x-ray absorptiometry (DXA) of the axial 
skeleton (77080) and dual-energy x-ray absorptiometry (DXA) of the appendicular skeleton (77081) provided 
on March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) device (E2103) and 
related supplies (A4239) provided on May 5, 2023. 
 
You asked the Plan to pay for a CGM and related supplies. You say that you have billed the items 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 KX or KS modifiers must be added to the 
code(s) on every claim submitted. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CGM and related supplies have not been met. Specifically, the items at issue have not been 
reported with one of the required modifiers. Therefore, we decided that the Plan does not have to pay for a 
continuous glucose monitor (CGM) device (E2103) and related supplies (A4239) provided on May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hepatitis A vaccine (90632) and administration (G0010) 
provided on July 25, 2023. 
 
You asked the Plan to pay for the immunization service. You say that you were under the impression that this 
was fully covered regardless of where it was administered. The Plan denied your request. The Plan says these 
are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization 
service. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization 
service. Therefore, we decided that the Plan does not have to pay for the Hepatitis A vaccine (90632) and 
administration (G0010) provided on July 25, 2023.   
Benefits for the immunization service 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no evidence to support the use 
of Leqvio for primary prevention of coronary artery disease. The enrollee has no evidence of development of 
clinically significant atherosclerotic cardiovascular disease (ASCVD) over an eight and a half year period. He 
has no significant symptoms. The records do not support that Leqvio is safe and effective and reasonable and 
medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Leqvio.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair (K0898) and hand or chin control 
interface, mini-proportional remote joystick (E2312) purchased on October 6, 2022, from a non-Medicare 
certified provider. 
 
You asked the Plan to pay for the power wheelchair and hand or chin control interface. You say that you had a 
stroke in 2018, have permanent disabilities and require mobility assistance. You also say that your previous 
wheelchair needed replacement parts that were no longer available as it was 14 years old, and is why you 
purchased another on October 6, 2022. The Plan denied your request. The Plan says the items were purchased 
from a provider who is not under contract with the health plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the power wheelchair and hand or chin control interface have not been met. This provider is not 
part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for 
the power wheelchair (K0898) and hand or chin control interface, mini-proportional remote joystick (E2312) 
purchased on October 6, 2022, from a non-Medicare certified provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service March 10, 
2023. 
 
You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 3 for CPT code 99153. This means there is only a 
technical component for the CPT code. In this case, there is no work component relative value unit (RVU) 
associated with code 99153. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99153 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99153 billed for date of service March 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections performed with a specialist 
provided on June 30, 2023. 
 
You asked the Plan to waive the copayment for injections performed with a specialist. You say that you 
disagree with the copayment applied. 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 $35 
copayment for physician/practitioner services.  
You have been asked to pay a $35 copayment for injections performed with a specialist. This item/service falls 
within the 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 total you owe is $11.39, which is less than the standard copayment for 
injections performed with a specialist. Therefore, we decided that the Plan does not have to waive the 
copayment for injections performed with a specialist provided on June 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
February 22, 2023. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that these services were necessary 
and are supported as billed. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are 
considered bundled and 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 procedure code. 
 
We find that procedure codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power pressure-reducing mattress (E0181). 
 You asked the Plan to pre-approve a power pressure-reducing mattress. You say that the requested item is a 
necessity for the enrollee's care. The Plan denied your request. The Plan says the requested item 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 pre-approve a power pressure-reducing mattress. 
Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee has suffered a stroke and has right sided hemiplegia. The 
enrollee requires supervision with transfers and is still able to independent perform weight shifts and 
repositioning while in bed. The enrollee does not have a history of pressure wounds or skin breakdown. The 
enrollee does not require a power pressure-reducing air mattress. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power pressure-reducing mattress have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power pressure-reducing mattress (E0181).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection performed with a specialist 
provided on July 19, 2023. 
 
You asked the Plan to waive the copayment for an injection performed with a specialist. You say that you were 
advised the visit would be covered 100%. 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 $35 
copayment for physician/practitioner services.  
You have been asked to pay a $35 copayment for an injection performed with a specialist. This item/service 
falls within the 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 total you owe is $11.39, which is less than the standard copayment for 
an injection performed with a specialist. Therefore, we decided that the Plan does not have to waive the 
copayment for an injection performed with a specialist provided on July 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on May 
03, 2023. 
 
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that this was a necessary 
next step, and you do not know why the Plan is not paying for any of it. 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 $110 
copayment for in-network outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $110 copayment for the abdominal ultrasound. This item/service falls within the 
in-network outpatient diagnostic tests, including ultrasounds benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. However, since the allowed amount is less than the 
standard copayment, you only owe $58.43. Therefore, we decided that the Plan does not have to waive the 
copayment for the abdominal ultrasound provided on May 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 provided on May 15, 2023. 
 
You asked the Plan to pay for procedure code G0482. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0482 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records show that more 
than 21 drug classes were tested. There is a more appropriate code to bill for the services provided. Based on 
this information, we decided that Medicare rules for coverage of procedure code G0482 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0482 provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections performed with a specialist 
provided on July 03, 2023. 
 
You asked the Plan to waive the copayment for injections performed with a specialist. You say that you 
disagree with the copayment applied. 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 $35 
copayment for physician/practitioner services.  
You have been asked to pay a $35 copayment for injections performed with a specialist. This item/service falls 
within the 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 total you owe is $11.39, which is less than the standard copayment for 
injections performed with a specialist. Therefore, we decided that the Plan does not have to waive the 
copayment for injections performed with a specialist provided on July 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections performed with a specialist 
provided on July 06, 2023. 
 
You asked the Plan to waive the copayment for injections performed with a specialist. You say that you 
disagree with the copayment applied. 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 $35 
copayment for physician/practitioner services.  
You have been asked to pay a $35 copayment for injections performed with a specialist. This item/service falls 
within the 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 total you owe is $11.39, which is less than the standard copayment for 
a specialist visit. Therefore, we decided that the Plan does not have to waive the copayment for injections 
performed with a specialist provided on July 06, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment with bupivacaine provided on July 20, 2023. 
 
You asked the Plan to pay for bupivacaine. 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 Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (27096) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for treatment with bupivacaine provided on July 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36558 and 77001 billed for June 15, 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 36558 and 77001 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 36558 is insertion of tunneled centrally inserted central 
venous catheter, without subcutaneous port or pump; age 5 years or older. The definition of code 77001 is 
fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast 
injections through access site or catheter with related venography radiologic supervision and interpretation, and 
radiographic documentation of final catheter position) (List separately in addition to code for primary 
procedure). 
 
We find that CPT codes 36558 and 77001 are not supported in the medical record. Specifically, there is no 
documentation of the final position of the tip of the central venous device to support code 36558. Code 77001 
is an add-on code that was not billed with a required primary procedure code. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 36558 and 77001 billed for June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services billed with codes s 81226, 81240, 
81241, 81328 and 81401 for May 15, 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 codes were not billed as a single unit. 
 
The Plan must follow Medicare rules. The rules say that multiplex tests must be billed with only one testing 
code. 
 
We looked at the file and Medicare rules. The file shows that the panel was not billed with one single testing 
code. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes s 
81226, 81240, 81241, 81328 and 81401 for May 15, 2023.