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

 
We decided that the Plan does not have to pay for procedure code 88121 billed for date of service December 5, 
2022. You asked the Plan to pay for procedure code 88121. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this service is not covered when it is performed as a screening or without 
other diagnostic services. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, procedure code 88121, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for procedure code 88121 billed for date of service December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CDxBRACAnalysis with MyRisk (81432, 81433) provided 
on May 25, 2023. 
 
You asked the Plan to pay for CDxBRACAnalysis with MyRisk testing. You say that this testing was 
necessary and appropriate. The Plan denied your request. The Plan says you do not meet criteria for coverage 
of this test. 
 
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 pay for CDxBRACAnalysis with MyRisk testing. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is insufficient documentation to support medical necessity in this 
case. Only an order form for the test was provided. There are no physician notes or other medical records to support that this testing was medically necessary and appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CDxBRACAnalysis with MyRisk testing have not been met. Therefore, we 
decided that the Plan does not have to pay for CDxBRACAnalysis with MyRisk (81432, 81433) provided on 
May 25, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on April 
17, 2023. 
 You asked the Plan to pay for the ED services. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on April 17, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service March 29, 2023. 
 
You asked the Plan to pay for code 99285. You say that code 99285 was billed appropriately due to the 
complexity of the enrollee's condition. The Plan denied your request. The Plan says code 99285 is not 
supported by the medical record because the records do not support this level of care.  As a result, the Plan has 
downcoded this service to 99284. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 code 99285 Our reviewer says that code 
99285 is not supported in the medical record. Our reviewer found the patient presented with near-syncope and 
vomiting, was diagnosed with dehydration, and treated with intravenous fluids and an anti-emetic and 
discharged to home. A urinalysis, complete blood count and metabolic panel were essentially normal. Provided 
records in this case do not document 2 out of 3 of an extensive number of diagnoses or management options, an 
extensive amount and complexity of data reviewed and high risk of complication to meet criteria for medical 
decision making of high complexity and CPT code 99285.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service March 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 3, 2022, to July 2, 
2022. 
 You asked the Plan to pay for the home health services. You say that the required NOA is on file. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 4, 2022. The NOA was not received by the Plan until September 2, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from June 3, 2022, to July 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 15-21 drug classes 
(G0482) provided October 26, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that kindly process the claim towards payment. 
The Plan denied your request. The Plan says under Medicare rules, the number of definitive urine drug classes 
requested are 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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found for only one class of medication, opiates, would definitive testing be medically 
reasonable and necessary. The other 20 classes were not medically reasonable and necessary. The Medicare 
rules say definitive Urine Drug Testing (UDT) testing is covered under certain conditions to: Identify a specific 
substance or metabolite that is inadequately detected by a presumptive UDT; Definitively identify specific 
drugs in a large family of drugs; Identify drugs when a definitive concentration of a drug is needed to guide 
management; Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with the 
presentation, medical history, or current prescribed pain medication plan; Identify non prescribed medication or 
illicit use for ongoing safe prescribing of controlled substances; and Use in differential assessment of 
medication efficacy, side effects, or drug-drug interactions. These conditions were NOT present for the other 
20 classes of drugs. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive urine drug testing (UDT) for 15-21 drug classes (G0482) provided October 
26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eCoin percutaneous tibial nerve stimulation. 
 
You asked the Plan to pre-approve the eCoin device. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the eCoin percutaneous tibial nerve stimulation 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 the eCoin device. Our reviewer says 
that the requested eCoin device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental and is the subject of trials to show this 
therapy is as good or better than standard treatment for overactive bladder. Overall, there is a lack of clinical 
peer reviewed information to show that eCoin Percutaneous Tibial Nerve Stimulation is a safe and effective treatment for overactive bladder. Therefore, the reviewer found that the requested eCoin device is 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 eCoin device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve eCoin percutaneous tibial nerve stimulation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 23, 2023. 
 
You asked the Plan to pay for the medical services. You say that the diagnosis code billed is payable. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that R56.9 has an Excludes1 note in relation to G40.901. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the medical services have not been met. Therefore, we decided that the Plan does not have to 
pay for medical services provided on May 23, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service January 10, 2023. 
 
You asked the Plan to pay for the billed services. You say that physician's send specimens for testing. The Plan 
denied your request. The Plan says that duplicate testing is not reportable. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment for code 84443 is not 
supported. 
 
Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim 
or claim line are denied. We find that the file does not include sufficient evidence to support the Plans 
argument that billed codes 80053 and 85025 are duplicates. The case file does not include an additional billed 
claim or explanation of benefits for the codes on the date of service at issue. Based on this information, we 
decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for the 
lab testing billed for date of service January 10, 2023.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 additional trips. 
 
You asked the Plan to pre-approve 30 additional trips. You say that the enrollee requires transportation services 
to get to their dialysis appointments three times per week, which is keeping them alive. The Plan denied your 
request. The Plan says the enrollee has used 36 trips for 2023, so the requested services will exceed the benefit 
limit. 
 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 up to 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Specifically, as of October 23, 2023, the 
enrollee has used 36 trips for the 2023 plan year. Based on this information, we decided that this request 
exhausts and exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we decided 
that the Plan does not have to pre-approve 30 additional trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20526 billed for date of service July 24, 
2023.  
 
You asked the Plan to pay for procedure code 20526. You say that both wrists were injected. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 20526 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 20526 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 20526 billed for date of 
service July 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 2, 2022, to 
August 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was accepted, so this 
claim should be paid. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 2, 2022, to 
August 31, 2022.
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 July 10, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were incorrectly 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 July 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service June 9, 2023.  
You asked the Plan to pay for procedure code 20930. You say that this claim was coded properly. The Plan 
denied your request. The Plan says procedure code 20930 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 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service June 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Relistor tablet 150 milligrams (mg). 
 
You asked the Plan to pre-approve the medication. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Relistor tablet 150 
milligrams (mg).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections. 
 
You asked the Plan to pre-approve repeat epidural steroid injections. You say that this is medically necessary. 
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 repeat epidural steroid injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has not 
had 3 months or longer sustained improvement in pain relief and/or improvement in function of at least 50% 
measured from baseline using same scale. 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 repeat epidural steroid injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repeat epidural steroid injections.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a protective prosthetic sleeve. 
 
You asked the Plan to pre-approve a protective prosthetic sleeve. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that the requested item is not medically necessary. 
 
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 a protective prosthetic sleeve. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found you have bilateral lower extremity amputations (right transfemoral, left 
transtibial) since 1986 in the setting of electrocution injury. You have been a long-time prosthetic ambulator 
and work on a farm using your prostheses at a K3 level, including a recently provided microprocessor knee (C-
leg). Per the medical record provided (e.g. the certified prosthetist/orthotist (CPO) from July and the physiatry 
note from February) if the CPO had requested coverage for a functionally equivalent L5705 cover it would not 
have been controversial; however, that code does not describe the standard, rigid, more durable, plastic cover 
needed for your given particular work environment. L5999 is the most the appropriate code to use for the 
product requested and is 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 a protective prosthetic sleeve have been met. Therefore, we decided that the 
Plan has to pre-approve a protective prosthetic sleeve.  
 
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.