Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services (CPT code 99239) provided 
on February 6, 2021. 
 
You asked the Plan to pay for the hospital discharge services. 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. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, CPT code 99239 (1 Unit) 
remains not supported. The submitted discharge summary does not support hospital discharge day management 
of more than 30 minutes was performed. A documented duration of time of 31 minutes or more is required to 
support this code.  Based on this information, we decided that Medicare rules for coverage of the hospital discharge services have 
not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge services (CPT 
code 99239) provided on February 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from May 28, 2020, to June 1, 
2020. 
 
You asked the Plan to pay for the inpatient care. You say that the provider was underpaid $2,290.78. The Plan 
denied your request. The Plan says the claim was processed and paid correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient care have not been met. Specifically, the record indicates that the Plan has paid the 
Medicare Allowed Amount for this service. A Medicare provider should accept the Medicare Allowed Amount 
as payment in full.  In this case, the Plan is not responsible for paying the balance that remains after the Medicare allowed 
payment. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from May 
28, 2020, to June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve segmental PCD with calibrated pressure and full leg 
appliances (CPT code(s): E0652 and E0667). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 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 DME. Our physician reviewer 
found there is no documentation that meet all of the requirements listed in the LCD: Pneumatic Compression 
Devices (L33829) for Medicare coverage for the requested segmental PCD with calibrated pressure and full leg 
appliances. Provided records do not document "at least four weeks of regular, daily, multiple-hour home usage" 
of a standard pump as required by the LCD. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve segmental PCD with calibrated pressure and full leg appliances (CPT code(s): E0652 and 
E0667).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy administrative services, 
professional pharmacy services, care coordination, and all necessary supplies and equipment provided from 
November 29, 2021, through December 1, 2021, billed with code S9500. 
 
You asked the Plan to pay for the home infusion services as billed. You say that this care was medically 
necessary and should be paid. The Plan denied your request. The Plan says this code is not payable by 
Medicare. 
 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 S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the home infusion services as billed have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy administrative services, professional pharmacy services, care 
coordination, and all necessary supplies and equipment provided from November 29, 2021, through December 
1, 2021, billed with code S9500.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88312, 88361, 88305) 
provided on November 3, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says there is insufficient information to verify if the services were necessary. 
 
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 (CPT code(s): 
88312, 88361, 88305) provided on November 3, 2020, have been met. There is insufficient information to verify if the services were necessary. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code(s): 88312, 88361, 88305) provided on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency center services provided on September 10, 
2021, to September 11, 2021. 
 
You asked the Plan to pay for the emergency center services. You say that the service should be covered. The 
Plan denied your request. The Plan says there is no documentation indicating the provider was granted the 
exception via the Covid waiver. 
 
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 emergency center services 
provided on September 10, 2021, to September 11, 2021, have been met. Specifically, the records indicates that 
this facility is not affiliated with a hospital and there is no evidence to indicate that this facility was granted 
CMS privileges to function as a hospital under the COVID-19 waivers. Therefore, we decided that the Plan 
does not have to pay for the emergency center services provided on September 10, 2021, to September 11, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 5, 2021. 
 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 there is no provided documentation that supports the genetic panel as being medically reasonable 
and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We 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 there is no documentation of refractory, relapsing, metastatic or Stage III/IV cancer. There was no 
specific clinical rationale for the obtained testing. The review has determined that the enrollee did not meet the 
criteria for this testing. 
 
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 laboratory services provided to the enrollee on July 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic laparoscopy (49320) provided on March 12, 
2021. 
 
You asked the Plan to pay for the diagnostic laparoscopy (49320). You say that medical records support CPT 
code 49320 and payment should be considered. The Plan denied your request. The Plan says CPT code 49320 
is considered inclusive to CPT code 43620. 
 
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 49320 is a column II code to column I code 43620; however, 49320 
was 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 the diagnostic laparoscopy (49320). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that the documentation does not support a separate diagnostic procedure from the total gastrectomy. In this 
case, CPT 49320 would be inclusive to CPT 43621. 
 
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 diagnostic laparoscopy (49320) have not been met. Therefore, we decided 
that the Plan does not have to pay for the diagnostic laparoscopy (49320) provided on March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve segmental PCD with calibrated pressure and full leg 
appliances (CPT code(s): E0652 and E0667 x2). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, your records do not show that you have lymphedema 
extending onto the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not have to pre-
approve segmental PCD with calibrated pressure and full leg appliances (CPT code(s): E0652 and E0667 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 23, 2021, by 
an out-of-network provider. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services were not referred by a network provider or rendered in a participating 
facility. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 laboratory services provided on December 23, 
2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation services (CPT code 99152) provided on 
September 9, 2021. 
 
You asked the Plan to pay for the service. 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. 
 
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
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 service. Our reviewer found the documentation submitted 
did indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the billed service cannot be verified. The review has 
determined that the service was supported in the medical records provided. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the sedation services (CPT code 99152) provided on September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81321, 81206, 81210, 
81235, 81272, 81275, 81276, 81292, 81301, 81311, 81191, 81317, 81295, and 81298) provided on June 6, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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. Furthermore, for the 
codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301 and 81311: Medicare denies coverage 
when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be 
submitted for the panel. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(CPT code(s): 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, 81311, 81191, 81317, 81295, 
and 81298) provided on June 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is to be used for the 
treatment of (COPD). The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in average volume-assured pressure support (AVAPS) mode with Auto-EPAP (AE) that could be 
delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
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 the home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary.  You have a diagnosis of COPD, although there 
are no pulmonary function tests for confirmation.  You also have significant heart disease, obstructive sleep 
apnea (OSA) on continuous positive airway pressure (CPAP), and severe obesity. There was borderline carbon 
dioxide (CO2) retention when acutely ill one (1) year ago.  There is no arterial blood gas (ABG) done as an outpatient while stable to confirm chronic CO2 retention. Therefore, you do not qualify for a ventilatory 
support device. In any case, Medicare does not pay for a home ventilator when used as BiPAP. BiPAP, with or 
without AVAPS, has not been tried at home. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on June 29, 2021, billed with 
codes 80280 and 82542. 
 
You asked the Plan to pay for the lab testing. You say that the services were ordered by a network provider and 
should be paid. The Plan denied your request. The Plan says payment was made for these services on a 
previous claim. There is no evidence that more than one set of lab testing occurred on the date of service at 
issue. 
 
The Plan must follow Medicare rules. Medicare rules say that exact duplicate claims are auto-denied but can be 
appealed.  
 
We looked at the file and Medicare rules. Payment was made for the two codes at issue on August 9, 2021. The 
claim at issue is a duplicate claim submitted on September 8, 2021. There is no evidence that these tests were 
repeated on the same date of service. We find that denial as a duplicate claim is appropriate. Based on this 
information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on June 29, 2021, billed with 
codes 80280 and 82542.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair power seat elevation system (E2300), 
expandable controller (E2377), electronic connection (E2311), and harness (E2313). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that items 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 wheelchair accessories. Our 
reviewer says that the items are not medically necessary. Our physician reviewer found the patient's upper 
extremity strength and function support that the patient can control any power options through their own 
switches. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the wheelchair power seat elevation system (E2300), expandable controller 
(E2377), electronic connection (E2311), and harness (E2313).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine (72141). 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that this is necessary to understand 
the enrollee's pain. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the cervical spine. Our 
reviewer says that the requested MRI is not medically necessary. Our physician reviewer found detailed 
evidence of severe or progressive neurological abnormalities has not been documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical spine (72141).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility evaluation provided on March 
8, 2021. 
 
You asked the Plan to pay for the subsequent nursing facility evaluation. You say that this was a medically 
necessary visit that should be paid. The Plan denied your request. The Plan says payment was already made for 
this visit on a previous claim. 
 
The Plan must follow Medicare rules. Medicare rules say that exact duplicate claims must be denied but can be 
appealed. 
 
We looked at the file and Medicare rules. The file shows that a claim for these services was submitted to the 
Plan on March 31, 2021, with payment made on April 13, 2021. An exact duplicate claim was again submitted 
on August 6, 2021. We find this second claim was correctly denied as there is no evidence a second visit was 
provided on this date of service. Therefore, we decided that the Plan does not have to pay for the subsequent 
nursing facility evaluation provided on March 8, 2021.