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

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 2, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this was denied as a duplicate in error. 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 76641 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 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual depression screening (G0444) provided on 
November 8, 2022. 
 
You asked the Plan to pay for the annual depression screening. You say that you did not receive this service. 
The Plan denied your request. The Plan says the benefit for this service has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the annual depression screening have not been met. Specifically, the file shows that the Plan has 
previously paid for this service within the last calendar year. Therefore, we decided that the Plan does not have 
to pay for the annual depression screening (G0444) provided on November 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
February 24, 2021, to February 26, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was underpaid. The Plan denied your request. The Plan says there was no new documentation or clinical 
evidence presented to support an overturn of the initial audit findings. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found that in this case there was no clinical or laboratory evidence of acute 
respiratory failure with hypoxia. The enrollee was hemodynamically stable and required only 1-3 L 
supplemental oxygen. The review has determined that the documentation did not support diagnosis code 
J96.01.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from February 24, 2021, to February 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
18, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. 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 76641 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 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
19, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 19, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on September 1, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the item rendered is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device and appliance was used in an ambulatory surgical center. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliance 
provided on September 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service July 16, 
2022, to August 12, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the Plan's denial. 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 date of service July 16, 2022, to August 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from August 4, 2022, to 
August 9, 2022 at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
denial should be overturned, and payment should be made at the originally billed DRG. The Plan denied your 
request. The Plan says the medical records do not support diagnosis codes A41.9 and N17.0. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis codes A41.9 and N17.0 defined as sepsis, 
unspecified organism and acute kidney failure with tubular necrosis. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the documentation does not support diagnosis codes A41.9 and N17.0. Our physician reviewer found there 
was no clinical or laboratory evidence of sepsis or acute kidney failure with tubular necrosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from August 4, 2022, to August 9, 2022 at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assay of estrogens (82671), assay of gonadotropin; 
follicle stimulating hormone (FSH) (83001), assay of gonadotropin; luteinizing hormone (LH) (83002), assay 
of free thyroxine (84439) and assay of thyroid stimulating hormone (TSH) (84443) provided on May 16, 2022. 
 
You asked the Plan to pay for the assays of estrogens, FSH, LH, free thyroxine and TSH. You say that this 
testing was medically necessary. The Plan denied your request. The Plan says screening tests are not covered. 
 
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, the assays of estrogens, FSH, LH, free thyroxine and TSH, 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 the assay of estrogens (82671), assay of gonadotropin; follicle stimulating 
hormone (FSH) (83001), assay of gonadotropin; luteinizing hormone (LH) (83002), assay of free thyroxine 
(84439) and assay of thyroid stimulating hormone (TSH) (84443) provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-cement or re-bond crown (D2920) provided on 
September 8, 2022. 
 
You asked the Plan to pay for the re-cement or re-bond crown (D2920). You say that you did not have the 
option to choose which provider you saw during your visit. The Plan denied your request. The Plan says the re-
cement or re-bond crown (D2920) is not covered under the benefit package. 
 
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 re-cement or re-bond crown 
(D2920) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for a re-cement or re-bond crown (D2920) provided on September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80050 billed for date of service April 21, 
2022. 
 
You asked the Plan to pay for procedure code 80050. You say that these services were medically necessary and 
ordered by the enrollee's physician. The Plan denied your request. The Plan says this service is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for procedure code 80050 
billed for date of service April 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency care visit provided on 
September 02, 2022. 
 
You asked the Plan to waive the copayment for an emergency care visit. You say that you are disputing the 
share cost. 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for an emergency care visit. This item/service falls within the 
Emergency care 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 emergency care 
visit provided on September 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam (92014) provided on November 7, 
2022. 
 
You asked the Plan to pay for the medical eye exam. You say that you are appealing because this was supposed 
to be billed as a routine eye exam instead of a medical vision eye exam. You also say that the treating provider 
does receive your medical vision eye exam results from your retina specialist. The Plan denied your request. 
The Plan says you pay $30.00 for services from an in-network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. Routine eye exams are preventive eye exams without any medical 
eye problems. The records show that during this visit, your eye conditions were assessed and discussed, as well 
as refractive options, intraocular pressure, and dry eye and ocular surface disease. Based on this information, 
we decided that the Plan's rules for coverage of the medical eye exam have not been met. Therefore, we 
decided that the Plan does not have to pay for the medical eye exam (92014) provided on November 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erivedge (C9399). 
 
You asked the Plan to pre-approve Erivedge. You say that Erivedge The Plan denied your request. The Plan 
says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 Erivedge (C9399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the laparoscopy procedure performed by 
an out-of-network provider on July 27, 2022. 
 
You asked the Plan to waive the cost sharing for the laparoscopy procedure. You say that you live on a fixed 
income. 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 35% 
coinsurance for each out-of-network Medicare-covered outpatient surgery at an outpatient hospital facility. 
 
You have been asked to pay a cost share of $2843.92 for the laparoscopy procedure ($8125.50 allowed amount 
x .35 = $2843.92). This item/service falls within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
cost sharing for the laparoscopy procedure performed by an out-of-network provider on July 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
10, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was denied as a duplicate in error. 
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 76641 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 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 10, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 75736, 75736, and 75625 provided on August 14, 
2022. 
 
You asked the Plan to pay for procedure codes 75736, 75736, and 75625. You say that the medical records 
support the use of modifier XU with codes 75736, 75736, and 75625. The Plan denied your request. The Plan 
says that the medical records do not support the use of modifier XU with codes 75736, 75736, and 75625. 
 
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 codes 75736, 75736, and 75625 are column II codes to column I code 
37244; however, 75736, 75736, and 75625 were each billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 75736, 75736, and 75625. Our reviewer 
says that the medical records support the use of modifier XU with codes 75736, 75736, and 75625. Our 
reviewer found CPT codes 75736, 75736, and 75625 are supported as separately identifiable procedures, the 
use of modifier XU is appropriate. The record states that there was no prior catheter-based study, and a full 
diagnostic study was performed; the decision to intervene was based on the diagnostic study. According to the 
CPT codebook, diagnostic angiography is separately reportable in this scenario. The operative report states 
there was pelvic bleeding, but the site was not identified. This supports that the diagnostic angiography 
procedures were necessary to identify which vessel required intervention. According to HCPCS and CPT 
Codebook 2022, Radiology procedures-diagnostic radiology procedures of the Aorta and Arteries Guidelines, 
CPT codes 75736, 75736, and 75625 are allowed to be reported with modifier XU in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 75736, 75736, and 75625 have been met. Therefore, we 
decided that the Plan has to pay for procedure codes 75736, 75736, and 75625 provided on August 14, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for clinic service visit provided on June 07, 2022. 
 
You asked the Plan to pay for clinic service visit. 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 clinic service visit 
provided on June 07, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on 
October 07, 2022, to October 11, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you thought these 
services were covered in full. 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 $250 
copayment for in-network inpatient hospital care. 
 
You have been asked to pay a $250 copayment for an inpatient hospital stay. This item/service falls within the 
in-network inpatient hospital care 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 inpatient hospital stay provided on October 07, 2022, to October 11, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (code 99291) billed for date of 
service March 5, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says Original 
Medicare is responsible for coverage. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 5, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the critical care 
services (code 99291) billed for date of service March 5, 2022.