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

 
We decided that the Plan does not have to pay for procedure code 38999 rendered on September 6, 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 Current Procedural Terminology (CPT) code 38999 (1 unit) remains 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 38999 is "Unlisted procedure, hemic or lymphatic 
system." 
 
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 when reporting an unlisted 
procedure code, documentation should include service performed that does not have an assigned code. The medical record does not include sufficient documentation to support what procedure was performed to 
represent the code. 
 
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 procedure code 38999 rendered on September 6, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmic ultrasound provided on 
October 10, 2023. 
 
You asked the Plan to waive the copayment for an ophthalmic ultrasound. You say that you did not have an 
ultrasound. 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 $100 
copayment for Medicare-covered ultrasounds. 
 
You have been asked to pay a $100 copayment for an ophthalmic ultrasound. This item/service falls within the 
Medicare-covered 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 
$11.88. Therefore, we decided that the Plan does not have to waive the copayment for an ophthalmic 
ultrasound provided on October 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would be better served receiving 
therapy and nursing on a frequent basis than what is being offered by home health. You also say the enrollee will greatly benefit from SNF care to eventually return home with greater independence. The Plan denied your 
request. The Plan says criteria for SNF care are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer the enrollee does not require daily skilled nursing or therapy services. The enrollee does not 
meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve powered operated vehicle (scooter) repairs (K0739) 
from an out-of-network (OON) provider.  
You asked the Plan to pre-approve scooter repairs. You say that you would like to know if the part needed 
could be ordered from another company so it might arrive sooner. The Plan denied your request. The Plan says 
this request is not medically necessary. 
 
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 pre-approve scooter repairs. Our reviewer says that 
this request is not medically necessary. Our physician reviewer found you have a loaner chair while waiting for 
the repairs from an OON provider. Our reviewer also found that the Plan is relying on an in-network provider 
and meeting your needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of scooter repairs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve powered operated vehicle (scooter) repairs (K0739) from an out-of-network (OON) 
provider.  
 
Please Note: The record shows that the request for a powered operated vehicle (scooter) repair has already 
been approved to be provided by an in-network provider under approval numbers ending in *6836 and *3098. 
Please contact the Plan if you have questions regarding this.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided August 22, 2023, by an out-of-
network provider. 
 
You asked the Plan to pay for the office visit . You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider is not in-network with the Health Plan. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided August 22, 2023, by an 
out-of-network provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service May 3, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
 We 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 procedure code 99285. Our reviewer says 
that the documentation does not support the code billed. Our reviewer found the enrollee  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 for date of service May 3, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service May 22, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
 
 We 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 procedure code 99285. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee presented to the Emergency 
Department with generalized weakness. The enrollee was hemodynamically stable and had a relatively 
remarkable workup. The presenting problem was not a high/immediate threat to survival or physiological 
function. History/exam are medically appropriate but there is insufficient evidence of high level medical 
decision-making to justify code 99285. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 for date of service May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service April 13, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the codes should be paid separately. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. The 
documentation supports that this panel used the nucleic acid probe technique. There is no evidence that 
multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a single code 
with one unit of service should be used. Additionally, the MUE for CPT code 8750 is 1. The MAI value for this 
code is 3. You billed 4 units of this code, exceeding the MUE. The documentation does not provide a rationale 
regarding why 4 units of testing were needed to treat this specific enrollees condition. Based on this 
information, we decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the panel testing billed for date of service April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ear wax removal and the outpatient 
clinic visit provided on April 28, 2023. 
 
You asked the Plan to reduce the copayment for the ear wax removal and the outpatient clinic visit. You say 
that you expected a $5 copayment for these services. 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 $375 
copayment for outpatient hospital services. 
 
You have been asked to pay a $375 copayment for the ear wax removal and the outpatient clinic visit. 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. However, since the allowed amount is less than the standard 
copayment, you only owe $111.44. Therefore, we decided that the Plan does not have to reduce the copayment 
for the ear wax removal and the outpatient clinic visit provided on April 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 05, 2023, to July 10, 
2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 the laboratory services 
provided on July 05, 2023, to July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 30, 2023, billed with 
procedure codes 99100, 99140, and 00350-QK-P4. 
 
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 the billed codes are considered bundled and are 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services 
correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes 
the services performed.  
 
We looked at the file and Medicare rules. We have confirmed that codes 99100 and 99140 have a status 
indicator B and are not separately payable. Code 00350-QK-P4 has not been billed with an appropriate 
modifier and is not separately payable when billed on the same day as code 01844. Based on this information, 
we decided that Medicare rules for coverage of the practitioner services provided have not been met. Therefore, 
we decided that the Plan does not have to pay for practitioner services provided on June 30, 2023, billed with 
procedure codes 99100, 99140, and 00350-QK-P4.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and testing provided on July 15, 2023. 
 
You asked the Plan to pay for the office visit and testing. You say that you disagree with the denial. 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 the office visit and 
testing provided on July 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services for date of service August 22, 2023. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the anesthesia services for date of 
service August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sacroiliac-joint injections (G0260, J0665, Q9965) provided 
on August 22, 2023. 
 
You asked the Plan to pay for sacroiliac-joint injections. 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 G0260 should be reported with an imaging code 
specific to the imaging modality employed. 
 
We looked at the file and Medicare rules. The claim contains code G0260. The code has not been reported with 
a corresponding imaging code. Based on this information, we decided that Medicare rules for coverage of 
sacroiliac-joint injections have not been met.  
  Therefore, we decided that the Plan does not have to pay for sacroiliac-joint injections (G0260, J0665, Q9965) 
provided on August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on August 15, 2023 
provided on August 15, 2023. 
 
You asked the Plan to pay for an office visit (99214) provided on August 15, 2023. You say that obtaining 
authorization would be the surgeon and/or facilities responsibility. The enrollee did not have a choice on the 
anesthesiologist. 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 an office visit (99214) 
provided on August 15, 2023 provided on August 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the intracoronary stent placement provided 
on August 31, 2023, to September 01, 2023. 
 
You asked the Plan to waive the copayment for the intracoronary stent placement. You say that you were 
unaware the procedure was not covered. 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 $275 
copayment for outpatient surgery, including services provided at hospital and outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay a $275 copayment for the intracoronary stent placement. This item/service falls 
within the outpatient surgery, including services provided at hospital and outpatient facilities and ambulatory 
surgical centers 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 the intracoronary stent 
placement provided on August 31, 2023, to September 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87801, 87798, and 
87493 for date of service July 26, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with codes 87801, 87798, and 87493 for date of 
service July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 15 units of procedure code 88341 rendered on May 18, 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 15 units billed exceed the MUE. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly with the 
correct number of units. 
 
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 at issue is the number of units billed 
for procedure code 88341. There were six specimens reported and only one unit of service shall be reported for 
each separate specimen. 15 units billed was inappropriate. 
 
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 15 units of procedure code 88341 rendered on May 18, 2023.