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

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 85025-26, 82962-
26, and 82962-26-59 for April 7, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the codes are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 9 represents a code for which the concept of a professional/technical component does not 
apply. 
 
We looked at the file and Medicare rules. The procedure codes at issue were billed with -26 modifier; however, 
they have a PC/TC indicator of 9 and the concept of a PC/TC component does not apply. Therefore, we 
decided that the Plan does not have to pay for the laboratory services billed with codes 85025-26, 82962-26, 
and 82962-26-59 for April 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scan provided on May 24, 2023. 
 
You asked the Plan to pay for computed tomography (CT) scan. You say that you are appealing the claim 
payment 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 computed tomography 
(CT) scan provided on May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on May 10, 
2023, and billed with codes 87640, 87481, 87798, 87653, 81003, and 87086. 
 
You asked the Plan to pay for the UTI panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the UTI panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on 
May 10, 2023, and billed with codes 87640, 87481, 87798, 87653, 81003, and 87086.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 26, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service July 22, 
2023. 
 You asked the Plan to pay for procedure code 93042. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 
93010. 
 
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 93042 
is a column II code to column I code 93010. 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 93042 billed for date of service July 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73502-RT billed for July 26, 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 code is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 73502 has an OPPS status indicator of Q1(s) 
and was billed with code 99283, which has an OPPS status indicator of V. Code 73502 is not separately 
payable when billed with a code with an OPPS status indicator of V. Therefore, we decided that the Plan does 
not have to pay for procedure code 73502-RT billed for July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0481-90) provided April 6, 2023. 
 You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code G0481 is not supported in the medical record. The submitted medical records do not 
contain sufficient detail to support the billed charges. Of note, the medical records submitted do not include an 
order that specifically list what test(s) are to be performed in the custom panel. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing (G0481-90) provided April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on June 16, 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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 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 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 documentation from this date 
describes the patient as undergoing workup including drug screen and was diagnosed with depression with 
suicidal ideation, simple laceration, and was discharged home due to low risk and low complexity with plans 
for follow-up with the primary care provider (PCP). Although the history and exam were appropriate, the 
documentation does not sufficiently support a high level of medical decision-making. 
 
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 emergency room services (procedure code 99285) rendered on June 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service May 18, 
2023. 
 
You asked the Plan to pay for procedure code 99070. You say that you would like reimbursement. The Plan 
denied your request. The Plan says procedure code 99070 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 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87640, 
87653, and 87798 for date of service June 21, 2023. 
 
You asked the Plan to pay for the laboratory services billed with codes 87481, 87640, 87653, and 87798. 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 87481, 87640, 87653, and 87798 for 
date of service June 21, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the request is medically necessary. The Plan denied 
your request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of an 
intravenous bisphosphonate (such as zoledronic acid) before they will approve the requested drug, Prolia. 
Based on the medical records provided, there is no indication that the enrollee has tried and failed the required 
drug(s). Based on the medical records provided and the Medicare-approved major drug compendia, there is no 
indication that the Plan's required drug(s) would likely be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 24, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 billed for date of service August 15, 
2023.  
 
You asked the Plan to pay for procedure code G0480. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code G0480 is bundled into payment for code 80307. 
 
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 G0480 is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 G0480 billed for date of service August 15, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional skilled nursing visits (G0299). 
 
You asked the Plan to pre-approve the aide services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 
  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 aide services. Our physician 
reviewer found that the records does not indicate the enrollee has documented skilled nursing needs. Criteria 
are unmet. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional skilled nursing visits (G0299).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for medication used during an advanced imaging service 
provided on May 1, 2023.  
 
You asked the Plan to waive the coinsurance for medication used during an advanced imaging service. You say 
that the drug is required for the scan, and you were not aware of the additional cost. The Plan denied your 
request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for outpatient diagnostic tests.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% 
coinsurance for medication used during an advanced imaging service. The Plan contract does not clearly say 
enrollees must pay an additional cost share for medication required to perform an advanced imaging service. 
This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, 
we decided that the Plan has to waive the coinsurance for medication used during an advanced imaging service 
provided on May 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided May 4, 
2023.   
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that please see attached medical 
records. The Plan denied your request. The Plan says under Medicare guidelines, the ultraviolet light therapy 
system (E0691) requested 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 looked at the file, and Medicare rules. The medical record does not show any diagnosis of psoriasis. There 
is also no indication that intractable psoriasis, as there is no indication the enrollee has failed other treatments 
for psoriasis. There are also no other factors described that would justify treatment at home rather than 
alternative sites, like a clinic or the hospital. Based on this information, we decided that Medicare rules for 
coverage of the ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does 
not have to pay for the ultraviolet light therapy system (E0691) provided May 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29581 for date of service July 31, 2023. 
 
You asked the Plan to pay for procedure code 29581. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 CPT code. The rules also say that 
casting/splinting/strapping CPT codes shall not be reported for application of a dressing after a therapeutic 
procedure. 
 
 In this case, the CPT Code Manual definition of code 29581 is application of multi-layer compression system; 
leg (below knee), including ankle and foot. 
 
We find that CPT code 29581 is not payable as billed. Specifically, the documentation shows that the 
debridement procedure was performed on the right plantar hallux Stage I ulcer and right lateral leg Stage II 
ulcer. The medical records indicate that a 3-layer Unna boot compression dressing system was applied to the 
ipsilateral lower extremity as a post-debridement dressing. casting/splinting/strapping CPT codes shall not be 
reported for application of a dressing after a therapeutic procedure. Since the Unna boot application was 
performed at the same anatomic site as the wound care procedure, code 29581 is not separately payable. Based 
on this information, we decided that Medicare rules for coverage of procedure code 29581 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 29581 for date of service July 31, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (84443) provided on January 19, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 84443 is Thyroid stimulating hormone testing. 
 
We find that CPT code 84443 is not supported in the medical record. Specifically, the record did not include an 
order for the billed test. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (84443) 
provided on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99418 billed for date of service June 9, 2023. 
 
You asked the Plan to pay for procedure code 99418. You say that 99418 should be paid as billed because it is 
supported in the documentation. 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 99418 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99418 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99418 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99418 billed for date of service June 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the request for LTACH care is medically 
necessary. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.