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

 
We decided that the Plan does not have to pay for the office visit and injection rendered on February 13, 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 billed diagnosis is not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with an incorrect diagnosis 
code that does not support the appropriate laterality. 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 office visit and injection rendered on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is 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 code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 22, 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 is not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that claims submitted using the GY modifier may be auto-
denied.  
 
We looked at the file and Medicare rules. The file shows that the claim was billed with the -GY modifier and is 
auto-denied by Medicare. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a flex-walk system (L5981) and multiaxial ankle and hydraulic 
active dorsiflexion (L5968). 
 
You asked the Plan to pre-approve a flex-walk system and multiaxial ankle and hydraulic active dorsiflexion. 
You say that the services are necessary. The Plan denied your request. The Plan says that based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
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 flex-walk system and multiaxial ankle 
and hydraulic active dorsiflexion. Our reviewer says that the services are medically necessary. Our physician 
reviewer found Medicares policy recognizes that flex-walk feet and the various additions chosen by the 
treating team are part of the basic standard of care for all community K3 amputee ambulators given that the 
evidence of their benefits and superiority to less sophisticated alternatives are so well proven and long standing. There is no doubt that original Medicare would cover the requested prosthesis for this K3-level enrollee. 
Therefore, the requested foot (L5981, L5968) is medically 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 a flex-walk system and multiaxial ankle and hydraulic active dorsiflexion have 
been met. Therefore, we decided that the Plan has to pre-approve a flex-walk system (L5981) and multiaxial 
ankle and hydraulic active dorsiflexion (L5968).  
 
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 genetic testing provided on February 26, 2023, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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 an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 26, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided on February 22, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for a duplex scan. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 a duplex scan provided on February 22, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96366 rendered on December 13, 2022. 
 
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 96366-59 (2 Units) remains not supported, as the 
medical records do not include documentation to support the two units. 
 
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 96366 is "Intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report describes 
outpatient services for insulin treatment. In this case, the claim denied correctly as there is a more appropriate 
HCPCS code to report for service documented. 
 
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 96366 rendered on December 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging service (74176) provided on January 23, 2023. 
 
You asked the Plan to pay for the imaging service. You say that this service was medically necessary and was 
billed with accurate diagnoses. The Plan denied your request. The Plan says this claim was submitted with two 
incompatible diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a diagnosis code has an Excludes1 note, it is inappropriate to report the noted condition 
together with the condition with the note. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging service have not been met. Specifically, this claim was submitted with diagnosis codes 
K92.2 (gastrointestinal hemorrhage, unspecified) and K57.32 (diverticulitis of large intestine without 
perforation or abscess without bleeding). However, code K92.2 has an Excludes1 note with all codes within the 
K57 code set. This means it is generally inappropriate to report these diagnoses together. Therefore, we decided 
that the Plan does not have to pay for the imaging service (74176) provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve radiation therapy for treatment of osteoarthritis. 
 
You asked the Plan to pre-approve the treatment. You say that radiation therapy is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that radiation therapy is experimental/investigational for 
osteoarthritis. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 treatment. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that it appears that the crux of the denial is that the initial reviewer concluded that other standard 
treatments have not been attempted (and the file records describe that the clinical records do not explicitly 
describe failure of Capsicin, walking aids, physical therapy, joint injections or hyaluronic acid lubricant 
injections, nor orthotics. The radiation oncologist mentions, in the consultation note: Patient feels like they 
exhausted all ways of relieving pain and have found no success with any treatment So it is unclear what 
refractory means, what treatments were attempted and what would be standard of care when NSAIDs, 
stretching and show inserts fail. Nevertheless, radiation is an accepted standard and the bar of trying every 
other possible treatment seems arbitrary (especially some of the ones listed that may not have level 1 evidence 
to support utility specific for foot arthritis). Radiation for treatment-resistant osteoarthritis, based upon 
published literature and guideline statements (from Germany) would be considered to be furnished with 
accordance of accepted standards of care. 
 
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 treatment have been met. Therefore, we decided that the Plan has to pre-
approve radiation therapy for treatment of osteoarthritis.  
 
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 procedure code 88291 billed for date of service March 14, 
2023.   
You asked the Plan to pay for procedure code 88291. You say that no payment has been received for a single 
unit. 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 88291 is 1. The MAI value for this code is 3. You billed 3 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 88291 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88291 billed for date of service March 14, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 17, 2023. 
 
You asked the Plan to pay for the medical services. You say that you are a contracted Medicaid provider. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 17, 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 all laboratories must have a CLIA certificate in order 
to receive reimbursement from Federal programs.  
 
We looked at the file and Medicare rules. The file shows that the required CLIA number was not billed on the 
claim. 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 rendered on March 
17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) with chronic hypoxemic and hypercapnic respiratory failure, thus initiation of 
bilevel positive airway pressure (BIPAP) with or without average volume assured pressure support (AVAPS) 
should be initiated as opposed to going to home ventilation from the start. The enrollee has no documented use 
or failure of BIPAP with or without AVAPS. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services billed with code 99291 for March 
13, 2023, to March 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 billed diagnosis is not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with diagnosis codes that exclude each other. 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 critical care services billed 
with code 99291 for March 13, 2023, to March 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low dose computerized tomography (CT) scan for date of 
service February 2, 2023. 
 
You asked the Plan to pay for the low dose CT. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services provided are not a covered benefit. 
 
 The Plan must follow Medicare rules. Medicare rules say that low dose CT is only covered for certain 
indications. 
 
We looked at the file and Medicare rules. Review of the file does not include documentation to support that the 
enrollee met the following criteria: asymptomatic (no signs or symptoms of lung cancer), tobacco smoking 
history of at least 20 pack-years, and current smoker or one who has quit smoking within the last 15 years; 
Based on this information, we decided that Medicare rules for coverage of the low dose CT have not been met. 
Therefore, we decided that the Plan does not have to pay for the low dose computerized tomography (CT) scan 
for date of service February 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service January 29, 
2023, to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this was necessary to avoid complications. 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service January 29, 2023, to February 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the electrocardiogram (ECG) provided by 
an in-network provider on March 6, 2023. 
 
You asked the Plan to waive the deductible for the electrocardiogram (ECG). You say that you do not think 
you should have to pay the cost share. 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. Your 
contract with the Plan says that there is a $250 deductible which applies to in and out-of-network outpatient 
hospital services.  
 
 
 
 
 
 You have been asked to pay a $55.15 deductible for the electrocardiogram (ECG). The item or service you 
asked the Plan to waive the deductible for falls within the outpatient hospital services benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible which 
applies to outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the 
time the electrocardiogram (ECG) was provided on March 6, 2023. Therefore, we decided that the Plan does 
not have to waive the deductible for the electrocardiogram (ECG) provided by an in-network provider on 
March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99458 billed for date of service March 27, 
2023.   
You asked the Plan to pay for procedure code 99458. 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 99458 is 3. The MAI value for this code is 3. You billed 4 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 99458 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99458 billed for date of service March 27, 2023.