Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided May 23, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says Pneumatic compression devices, E0673 and E0675, were billed for use outside of the 
home and is not separately payable. 
 
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. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease 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 (E0675) and segmental pneumatic appliances (E0673) provided May 
23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482) provided July 19, 2022. 
 
You asked the Plan to pay for the drug testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 G0482 is Drug test(s), definitive, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show at 
least 15 drug classes were tested. 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 drug testing 
(G0482) provided July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00142, 99100) provided on December 
22, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 codes 00142 & 99100 are not supported in the medical record. Specifically, code 99100 has a 
status of "B" and is not separately payable Code 00142 was not billed with the required QX or QZ modifier. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not 
been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (00142, 99100) 
provided on December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (G0446, G0442) provided on August 5, 
2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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 definitions of codes G0446 and G0442 are face-to-face intensive behavioral 
counseling for cardiovascular disease, individual, 15 minutes and Screening for alcohol misuse and brief 
behavioral counseling. 
 
We find that CPT code G0446 and G0442 is not supported in the medical record. Specifically, these services were billed with the 25 modifier but are not evaluation and management services. Based on this information, 
we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we 
decided that the Plan does not have to pay for physician services (G0446, G0442) provided on August 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested ventilator is not medically reasonable or necessary. Our physician reviewer found that this patient 
has COPD, recurrent aspiration pneumonia, and chronic cough.  There is no diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease. Medicare does not cover this device for COPD because there is 
inadequate evidence of safety and effectiveness for this diagnosis. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 May 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided on September 13, 
2022. 
 
You asked the Plan to pay for the emergency room visit. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the billed code cannot be paid. 
 
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 99285 is not supported in the medical record. Specifically, another physician of the 
same specialty provided an evaluation and management service for the same problem on the same date of 
service. Based on this information, we decided that Medicare rules for coverage of the emergency room visit 
have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit 
(99285) provided on September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services (J02501, 90999) provided on August 1, 
2022. 
 
You asked the Plan to pay for the dialysis services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code J02501 and 90999 is not supported in the medical record. Specifically, less than 7 
treatments were provided. This service requires the G6 modifier. Modifier G3 was billed. Based on this 
information, we decided that Medicare rules for coverage of the dialysis services have not been met. Therefore, 
we decided that the Plan does not have to pay for dialysis services (J02501, 90999) provided on August 1, 
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 
January 26, 2022, to January 31, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says there was no treatment, monitoring, or 
additional workup for the diagnosis to support reporting J90 as a secondary diagnosis. 
 
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 of pleural effusion, not elsewhere 
classified. 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 the enrollee was treated in the hospital with altered mental 
status. Workup revealed hypoglycemia. He was treated with D50 and mental status improved. Initial CT 
imaging noted no pleural effusion with repeat CT chest noting small dependent pleural effusion. However, this 
effusion was not treated in any way and did not lead to additional testing related to such to justify including 
pleural effusion as a secondary diagnosis for this admission as it was not significant to the hospital course.   
 
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 January 26, 2022, to January 31, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 
87581, 87634, 87640, 87798, U0003, U0005) provided on August 11, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says that this claim is denied. 
 
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 has not provided a clear reason for denial with a 
supporting citation and evidence. The Plan's denial is not substantiated in this case. Therefore, we decided that 
the Plan has to pay for the laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 
87640, 87798, U0003, U0005) provided on August 11, 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 anesthesia services (procedure code 01810) received on 
September 16, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says diagnosis codes should indicate laterality, specifying whether the condition occurs on the left, 
right, or bilateral. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The claim shows multiple diagnosis codes billed, including G56.11 and G56.12, for other lesions of median 
nerve, right upper limb and left upper limb. There is a more comprehensive diagnosis code available to use in 
this case. This diagnosis code is G56.13 - other lesions of median nerve, bilateral upper limbs. 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 anesthesia services (procedure code 01810) received on 
September 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided June 29, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery.  
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. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease 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. The enrollee used the equipment in the facility during 
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for 
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that 
the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic 
appliances (E0673) provided June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient visit (99204) provided on June 3, 2022. 
 
You asked the Plan to pay for the new patient visit. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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 99204 is Office or other outpatient visit for the evaluation 
and management of a new patient. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, records show another visit 
with this provider in the enrollee's history on May 24, 2022. Based on this information, we decided that 
Medicare rules for coverage of the new patient visit have not been met. Therefore, we decided that the Plan 
does not have to pay for a new patient visit (99204) provided on June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 88112, 88305, 88312 and 
88361 provided April 25, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the Plan does not have the information 
needed to consider this charge. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
records were required to verify that the services were medically necessary. No records were provided, and the 
medical necessity criteria cannot be determined. Therefore, we decided that the Plan does not have to pay for 
the laboratory services coded as 88112, 88305, 88312 and 88361 provided April 25, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 10, 2022, to 
July 9, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. 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 June 10, 2022, to July 9, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this procedure fills a treatment gap for those 
patients that do not receive adequate relief from traditional conservative methods. The Plan denied your 
request. The Plan says there are currently no clinical indications for this technology. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the procedure is experimental. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 22, 2022. 
 
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 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 August 22, 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 September 
22, 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 September 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99204 billed for date of service May 2, 2022. 
 
You asked the Plan to pay for code 99204. You say that you would like this claim paid. The Plan denied your 
request. The Plan says code 99204 was billed incorrectly. 
 
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 99204 is New patient office or other outpatient visit, 45-
59 minutes. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, Medicare rules define a new 
patient as a patient who has not received any professional services from the physician or physician group practice within the previous three years.  In this case, the patient received professional services from another 
provider within the group (using the same taxonomy code), on July 17, 2021.  Because this date is within 
Medicare's 3-year window, the patient cannot be considered a 'new patient' for purposes of billing.  As a result, 
code 99204 was not appropriately billed in this case, as that code is used only for new patient visits. Based on 
this information, we decided that Medicare rules for coverage of code 99204 have not been met. Therefore, we 
decided that the Plan does not have to pay for code 99204 billed for date of service May 2, 2022.