Persius/hicric huggingface dataset:
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 July 
13, 2021, to July 15, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the removal of code E43, as this diagnosis is supported based on physician documentation of condition and clinical evidence including decreased intake, weight loss, and loss of muscle mass. The Plan 
denied your request. The Plan says the DRG was updated. 
 
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 DRG 643. 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 review has determined that the documentation did not support diagnosis code E43 - unspecified severe 
protein-calorie malnutrition. The records support DRG 644 in this case. There was no weight history provided 
to support the amount of weight loss reported. Furthermore, there is documentation in the history and physical 
that the patient denied any initial weight loss. There was no clinical or laboratory evidence of severe protein 
calorie malnutrition.  
 
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 July 13, 2021, to July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6219 and A6222 billed for date of service 
September 2, 2022. 
 
You asked the Plan to pay for procedure codes A6219 and A6222. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure codes A6219 and A6222 are 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 codes A6219 and A6222 have a status indicator of P on the Physician Fee Schedule. 
This means that these are bundled/excluded codes and there are no relative value units (RVUs) and no payment 
amounts for these services. Based on this information, we decided that Medicare rules for coverage of procedure codes A6219 and A6222 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A6219 and 
A6222 billed for date of service September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG); recording in coma or sleep 
only provided to the enrollee on May 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 Current Procedural Terminology (CPT) code 95822 26 (1 Unit) remains not supported. 
 
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 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep only." 
 
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 technical report does indicate 
that an EEG was performed. However, CPT 95822 is not supported as the enrollee was not in a coma or sleep. 
There appear to be more appropriate codes to typically use in this clinical scenario. (e.g., 95812 and 95813). 
 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 electroencephalogram (EEG); recording in coma or sleep only provided to the enrollee on May 
16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza (flu) vaccine (90662), and administration 
(G0008) provided on October 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vaccine services. You say that you were not aware that you were limited to 
where you could get a flu shot and it be covered. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the influenza (flu) vaccine (90662), and administration (G0008) 
provided on October 10, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the physical therapy treatments  
(97039 x 20), office visits (99211-GY, 99213-GY), and the cranial cervical orthosis (L0112) provided from 
April 28, 2022, through June 23, 2022. 
 
You asked the Plan to issue reimbursement for these items/services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these 
items/services at issue are not payable. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physicians order and proof of delivery. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue (97039) are not manual manipulation of the spine. The rules say that 
the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 
Codes 99211 and 99213 were billed with a GY modifier, indicating a service that is statutorily non-covered. 
The Plan Evidence of Coverage (EOC) says that covered services include: For new patients, one visit covered 
every three (3) years; For established patients, one visit covered every year. You had an office visit indicated as 
code (99203) on April 28, 2022, which was paid for by the Plan. Since your 2022 EOC states the Plan will 
cover one visit every year, you have exhausted the allowable benefit for this service. The provider billed both 
codes 99211 and 99213, because they knew you exhausted your benefit and these codes cannot be paid for by 
the Plan. Furthermore, the record does not contain a valid physician order, proof of delivery, or relevant 
medical records which support the medical necessity of the cranial cervical orthosis (L0112) provided in this 
case. Additionally, this item was not provided by an approved supplier. Therefore, we decided that the Plan 
does not have to issue reimbursement for the physical therapy treatments (97039 x 20), office visit (99211-GY, 
99213-GY), and the cranial cervical orthosis (L0112) provided from April 28, 2022, through June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 13, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating providers are not covered under open access unless preauthorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on July 13, 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 
12, 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 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided during anterior 
colporrhaphy and colpopexy provided on May 4, 2022. 
 
You asked the Plan to pay for the assistant surgeon services provided during anterior colporrhaphy and 
colpopexy. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services rendered are not payable. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
provided during anterior colporrhaphy and colpopexy provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87801) provided on June 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. 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 (87150, 87801) provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services (procedure code 
99239) provided to the enrollee on January 9, 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 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 99239 is "Hospital discharge day management; more than 
30 minutes." 
 
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 a documented duration of time of 
31 minutes or more is required to support this code. Therefore, the billed service cannot be verified. 
 
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 hospital discharge day management services (procedure code 99239) provided to the enrollee 
on January 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
documentation does not support that the requested ventilator is medically reasonable or necessary. Our 
physician reviewer found you have a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease. The provided records document that the home ventilator is being requested for use in 
average volume assured pressure support (AVAPS) mode with auto-titration (AE) which could be provided by 
a BiPAP device with AVAPS and a back-up rate. Therefore, you do not meet criteria for the requested device.  
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the radiation therapy services provided 
from August 4, 2022, to August 31, 2022. 
 
You asked the Plan to waive the cost sharing for the radiation therapy services. You say that you do not 
understand the cost sharing amount. 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 20% 
coinsurance of the total cost for Medicare-covered therapeutic radiology services. 
 
 
 
 
 
 
 You have been asked to pay a cost share of $1060.85 for the radiation therapy services. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
These items/services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 radiation therapy services provided from 
August 4, 2022, to August 31, 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 
21, 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 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 17, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this claim 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 76642 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 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service October 17, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on June 3, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says 
Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 
calendar year from the date the services were furnished. The claim was received on October 12, 2022, which is 
past the allowed 12-month timeframe. 
 
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 emergency department visit was not filed until October 12, 2022. 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 an emergency department visit provided on 
June 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76380 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for procedure code 76380. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76380 is bundled into payment for code 37243. 
 
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 76380 
is a column II code to column I code 37243. 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 76380 billed for date of service July 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical access hospital services provided on  
February 8, 2022. 
 
You asked the Plan to pay for critical access hospital services. The Plan denied your request. The Plan says 
critical access hospital services requires a rate sheet be submitted with claim. 
 
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 critical access hospital services have been met. Critical access hospital services requires a rate sheet be submitted with claim. Therefore, we decided 
that the Plan does not have to pay for critical access hospital services provided on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) provided to the 
enrollee on August 1, 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 three attempts on dates of 12/06/2022, 12/13/2022, and 12/23/2022, were made to obtain the 
medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records in this case lack clinical detail with regard to patient specific indications, 
including historical use, medication response, and clinical assessment, indicating accurate results were 
necessary to make clinical decisions. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (procedure code G0483) provided to the enrollee on August 1, 2022.