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

 
We decided that the Plan does not have to pay for three units of procedure code 88291 billed for January 10, 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 23, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for three units of procedure code 88291 billed for January 10, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network urologist. 
 
You asked the Plan to pre-approve these services. You say that you need to see the provider based on your 
condition. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The file shows that you have not 
previously seen this provider. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network urologist.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic exam of the large bowel to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a diagnostic exam of the large bowel to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a diagnostic exam of the large bowel to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services coded as 87481, 87500, 87640, 87652, 87653 
and 87798 provided December 1, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are a third-party diagnostic lab. The 
treating physician orders your tests, and you provide the results. The Plan denied your request. The Plan says 
that the entity or provider cannot be located. 
 
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. The Plan denied that the entity or provider cannot be located but has not 
provided any information to clarify this reason to deny or documentation to support their reason to continue to 
deny. The Plan has not provided information on whether the referring provider is in-network. The Plan has not 
substantiated their reason to continue to deny. Therefore, we decided that the Plan has to pay for the laboratory 
services coded as 87481, 87500, 87640, 87652, 87653 and 87798 provided December 1, 2022.  
 
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(s) 88305 billed for date of service March 9, 
2023. 
 You asked the Plan to pay for procedure code(s) 88305. You say that you have provided medical records to 
support payment. 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 the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service March 9, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150 billed for date of service January 10, 
2023. 
 
You asked the Plan to pay for procedure code 87150. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87150 is bundled into payment for code 87500. 
 
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 87150 
is a column II code to column I code 87500. This claim has not been billed with an appropriate modifier to 
bypass the edit. The XU modifier is not supported as a separate and distinct procedural service. 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 87150 billed for date of service January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80324, 80346, 80348, 80353, 80354, 80355, 
80356, 80358, 80359, 80361, 80362, 80365, 80368, 80369, and 80371 billed for date of service January 3, 
2023. You asked the Plan to pay for the billed services. You say that the test is a Medicare covered service. 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 codes 80324, 80346, 80348, 80353, 80354, 80355, 80356, 80358, 80359, 80361, 
80362, 80365, 80368, 80369, and 80371 have a Status Indicator of I on the Physician Fee Schedule. This 
means that the procedure codes are not valid for Medicare purposes. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 80324, 80346, 80348, 80353, 80354, 80355, 80356, 80358, 80359, 80361, 
80362, 80365, 80368, 80369, and 80371 billed for date of service January 3, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on August 
9, 2022, billed with codes 71101 and A4930. 
 
You asked the Plan to pay for the ED services as billed. You say that you believe that additional payment 
should be made as the payment received does not cover the expenses for the treatment provided.  The Plan 
denied your request. The Plan says this was paid correctly as no payment can be made for the denied codes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 71101 has a status indicator of Q1 on the Outpatient Prospective Payment System (OPPS). This means 
that it is packaged in payment for any S, T, or V indicator codes on the claim. Code 99284 has a status 
indicator of V and was paid. In addition, code A4930 has a status indicator of N in the OPPS. This means that 
payment is always packaged with other services. Based on this information, we decided that Medicare rules for 
coverage of the ED services as billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the emergency department (ED) services provided on August 9, 2022, billed with codes 71101 and 
A4930.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service December 8, 
2022. 
 
You asked the Plan to pay for procedure code 88341. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 88341 is bundled into payment for code 88360. 
 
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 88341 
is a column II code to column I code 88360. 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 88341 billed for date of service December 8, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
November 26, 2022, though December 1, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted for acute inpatient psychiatric hospitalization on November 23, 2022 with 
Adjustment Disorder with Depressed and Anxious Mood. Based upon the review of the records provided, it 
was not expected that this enrollee would improve in a reasonable period of time for the dates in question as 
she did not have suicidal or homicidal ideation, or auditory and visual hallucinations. The enrollee was 
compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary 
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 
care beyond the date in question as she did not have dangerousness to self or others and was compliant with her 
treatment. The health plans denial of continued inpatient psychiatric services is appropriate. This enrollee did 
not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to 
herself or others and did not have auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services were reasonably expected to 
improve the enrollees condition or were for the purpose of a diagnosis beyond the date in question. It did 
appear that the records were supervised and evaluated by a physician. Based upon the review of the records 
provided, the enrollee does not meet the criteria for coverage of the acute inpatient psychiatric hospital care 
provided from November 26, 2022 forward as this enrollee was not shown to be a danger to herself or others. 
She did not have delusions or auditory and visual hallucinations as noted. She was cooperative/compliant with 
treatment while not showing any threats  safety. 
  
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 pay for the acute inpatient psychiatric hospital care provided from November 26, 2022, though 
December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87500 billed for date of service February 13, 
2023.  
 
You asked the Plan to pay for procedure code 87500. You say that the medical records provided support the 
necessity of the services in dispute. 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 87500 is 1. 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 87500 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87500 billed for date of service February 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76000 billed for date of service January 3, 
2023. 
 
You asked the Plan to pay for procedure code 76000. The Plan denied your request. The Plan says payment for 
code 76000 is bundled into payment for code 22849. 
 
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 76000 is a column II code to column I code 22849. Code 76000 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 76000 
billed for date of service January 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus liquid biopsy CGP panel (81455) provided 
February 10, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that you are writing this letter to request coverage 
for the Tempus liquid biopsy CGP panel. The Plan denied your request. The Plan says the requested test is not 
reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The Tempus xF has not had FDA approval or clearance as a 
companion in vitro diagnostic or an FDA-approved or -cleared indication for use in this patients cancer. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Tempus liquid biopsy CGP panel (81455) 
provided February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on December 12, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you do not think that the provider 
is a specialist. 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 $50 
copayment for each covered visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a $50 copayment for an office visit. This item/service falls within the each covered 
visit or consultation in an outpatient location with a specialist 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 an office visit provided on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
February 24, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that it is the 
responsibility of the facility to obtain prior authorization. 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 a home visit for the 
evaluation and management provided on February 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically necessary 
to prevent blood clots and aid in healing. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service and is not eligible for 
reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Molecular pathology procedure; physician interpretation 
and report (G0452) provided January 14, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you received this account into your accounts 
receivables on July 1, 2022, and billed a corrected claim March 10, 2023. Please review your system notes and 
reprocess this claim for payment. The Plan denied your request. The Plan says the claim was received past the 
timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory service was not filed until March 13, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the Molecular pathology procedure; physician interpretation and 
report (G0452) provided January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an overdenture (D5863) and mini-implants (D6013 2 
units). 
 
You asked the Plan to pre-approve dental services. You say that it is difficult for the enrollee to eat. The Plan 
denied your request. The Plan says code D5863 is not covered by the Plan and the Plan only covers 2 units of 
D6013 per calendar year which has already been approved. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested overdenture D5863 is not 
among the services covered by the Plan. While mini-implant D6013 is covered by the Plan, the Plan has 
already approved 2 units of this code; therefore, the benefit has been exhausted for the calendar year. 
Therefore, we decided that the Plan does not have to pre-approve an overdenture (D5863) and mini-implants 
(D6013 2 units).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network chiropractic visits provided 
from January 9, 2023, to January 25, 2023. 
 
You asked the Plan to waive the copayment for in-network chiropractic visits. You say that you should not 
have these copayments. 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 $7 
copayment for chiropractic services.  
 
You had six appointments with this chiropractor, resulting in a $42 total copayment ($7 x 6 = $42). 
 
 You have been asked to pay a $42 copayment for in-network chiropractic visits. This item/service falls within 
the chiropractic 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. Therefore, we decided that the Plan does not have to waive the copayment for in-network 
chiropractic visits provided from January 9, 2023, to January 25, 2023.