Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92960 billed for date of service May 22, 
2022. 
 You asked the Plan to pay for procedure code 92960. You say that this service was reported correctly and can 
be paid separately. The Plan denied your request. The Plan says payment for code 92960 is bundled into 
payment for code 99291. 
 
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 92960 
is a column II code to column I code 99291. 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 92960 billed for date of service May 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasounds (CPT code 76642-26-LT and 76642-
26-RT) provided on July 25, 2022. 
 
You asked the Plan to pay for the breast ultrasounds. You say that the claim should be paid. 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 cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed two (2) units of 
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
breast ultrasounds have not been met. Therefore, we decided that the Plan does not have to pay for the breast 
ultrasounds (CPT code 76642-26-LT and 76642-26-RT) provided on July 25, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the noncovered item or service, self-administered drugs 
(A9270) provided August 29, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that this was more than an overnight stay 
solely for observation. It was obviously for further evaluation, rehydration and stabilization. The Plan denied 
your request. The Plan says these codes are for self-administered drugs given to the member while they are in 
outpatient basis at a facility and are apt to be covered under the enrollees Part D coverage. 
 
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 pay for the noncovered item or service, 
self-administered drugs (A9270) provided August 29, 2022.  
 Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care services provided from  
September 10, 2021. to October 6, 2021. 
 
You asked the Plan to pay for home health services. The Plan denied your request. The Plan says the RAP was 
not received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an RAP must be submitted within 5 days of the start of 
care date for home health services. RAPs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 10, 2021. The NOA was not received by the Plan until 
December 27, 2021. As more than 30 days passed between the timely filing date and the RAP receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health 
care services provided from September 10, 2021. to October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (tens) device, 
four or more leads, for multiple nerve stimulation (E0730) provided July 4, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the claim was billed in accordance with the 
enrollee's Plan allowable, accepted procedure codes, and diagnosis codes according to the Plan type. The Plan 
denied your request. The Plan says evidence of misrepresented services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the proof of delivery did not include an order 
number or details to corroborate the Delivery Ticket submitted. Of note, the Proof of Delivery is not itemized 
to indicate the specific supplies. The Plan was also unable to verify an established relationship with the 
referring provider and the enrollee. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation 
(E0730) provided July 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Level IV Surgical pathology services (88305) provided 
on May 10, 2022. 
 
You asked the Plan to pay for procedure code 88305. You say that you would like the Plan to reconsider their 
denial of payment. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We looked at the file and Medicare rules. We find that procedure code 88305 is not supported in the 
documentation provided.  Specifically, the file shows that a prostate needle biopsy specimen was submitted 
with procedure code 55700. Medicare requires that surgical pathology, including gross and microscopic 
examination, of all submitted prostate needle biopsy specimens be reported with one unit of service of 
procedure code G0416 rather than procedure code 88305. Based on this information, we decided that Medicare 
rules for coverage of procedure code 88305 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Level IV Surgical pathology services (88305) provided on May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0651) and segmental 
pneumatic appliance (E0667) provided June 7, 2022. 
 You asked the Plan to pay for the pneumatic compression device and appliance.. You say that you called the 
Plan on June 7, 2022 and was informed that you did not need to obtain pre-authorization for the equipment. 
The Plan denied your request. The Plan says based on Medicare guidelines, the pneumatic compression device 
(E0651 and E0667) does not meet the requirements for approval. 
 
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 find that CPT code E0651 and E0667 is not supported in the medical record. Specifically, the 
records show that the enrollee had knee surgery on June 6, 2022, and this device was used to help prevent 
blood clots after the surgery. The correct coding for this device for prevention of deep venous thrombosis is 
E0676. 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 to you, for this service is the responsibility of the 
facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for 
coverage of the pneumatic compression device and appliance. have not been met. Therefore, we decided that 
the Plan does not have to pay for the pneumatic compression device (E0651) and segmental pneumatic 
appliance (E0667) provided June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on March 10, 2022. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were not authorized. 
 
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 a hospital outpatient clinic visit provided on March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker, folding, wheeled, adjustable or fixed height 
(E0143) purchased July 13, 2022. 
 
You asked the Plan to pay for a walker. You say that the denial indicates that the services received are not 
covered by Medicare. However, the 2022 issue of "Medicare and You" indicates, on page 40, that walkers are 
covered under Durable Medical Equipment (DME). The Plan denied your request. The Plan says the DME was 
purchases from a provider that is not a participating Medicare provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a walker, folding, wheeled, adjustable or 
fixed height (E0143) purchased July 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 18, 2021 to 
October 23, 2021, 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 you 
disagree with the denial. The Plan denied your request. The Plan says the DRG is not supported. 
 
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 code N17.0. 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 submitted records do not support the billing of diagnosis code N17.0. Our physician 
reviewer found based on the submitted records, the enrollee was without clear and consistent provider 
documentation support or clinical indicators related to the findings of acute kidney injury (AKI) due to 
vasomotor nephropathy. Collected urinalysis did not have any lab abnormalities consistent with the diagnosis 
of acute tubular necrosis such as non-hyaline (granular or muddy casts). No Urinary sodium noted in chart 
documentation for review. The records do not support the billing of diagnosis code N17.0.  
 
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 on October 18, 2021 to October 23, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 22, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the 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 cannot be paid when the MAI value is 2.  
 
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. 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 August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel identified with code 87632 
provided on July 8, 2022. 
 
You asked the Plan to pay for the respiratory pathogen panel. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with greater than 5 respiratory pathogens 
performed in the outpatient setting are not covered. 
 
We looked at the file and Medicare rules. The service at issue is Infectious agent detection by nucleic acid 
(DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, 
parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets. This service is 
specifically not covered. Based on this information, we decided that Medicare rules for coverage of the respiratory pathogen panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory pathogen panel identified with code 87632 provided on July 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97810, 97811) billed for dates of 
service from February 16, 2022, to February 28, 2022. 
 
You asked the Plan to pay for acupuncture services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for acupuncture services have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that auxiliary personnel furnishing acupuncture must 
be under the appropriate level of supervision of a physician, PA, or NP/CNS. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acupuncture services have not been met. Specifically, the available medical records do not 
document the supervision of a physician, PA, or NP/CNS. Therefore, we decided that the Plan does not have to 
pay for acupuncture services (97810, 97811) billed for dates of service from February 16, 2022, to February 28, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not approved because the enrollee did not have a 3 
consecutive day inpatient hospital stay. 
 
The Plan must follow Medicare rules. Medicare rules say that beneficiaries must have been an inpatient of a 
hospital for a medically necessary stay of at least 3 consecutive calendar days for SNF services to be approved.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF care have not been met. Specifically, the documentation does not show that the enrollee had a 
3-day inpatient hospital stay prior to this request. Therefore, we decided that the Plan does not have to pre-
approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA), multiple organisms; amplified probe(s) technique (87801) infectious agent detection by nucleic acid 
(DNA OR RNA), not otherwise specified; amplified probe technique, each organism (87798) infectious agent 
detection by nucleic acid (DNA OR RNA); candida species, (87481) provided April 12, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the procedures done are essential with the 
other services rendered on the same day and none of them require prior authorization. The Plan denied your 
request. The Plan says the services are experimental and investigational. 
 
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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found after careful review of the enclosed information and the pertinent guidelines for this 
case, the requested PCR testing of affected symptomatic toenails is not medically reasonable or necessary.  It is 
well established that this enrollee presents complaining of elongated thickened dystrophic painful toenails.  The 
enrollee s toenails are not responding to application of ketoconazole 2%. In this particular case the enrollees 
toenails have already not responded to ketoconazole 2% which is an efficacious topical antifungal medication. 
There is no documentation that toenails have been sent for a much less expensive but still effective test 
including KOH and fungal culture. Both KOH and fungal culture are inexpensive and currently standard of 
care for the diagnosis of onychomycosis. It appears that PCR testing of this enrollees toenails is not standard 
of care, and possibly exceeds the enrollees medical need.  
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; 
amplified probe(s) technique (87801) infectious agent detection by nucleic acid (DNA OR RNA), not 
otherwise specified; amplified probe technique, each organism (87798) infectious agent detection by nucleic 
acid (DNA OR RNA); candida species, (87481) provided April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for that home COVID-19 tests provided to you on May 16, 
2022. 
 
You asked the Plan to pay for the tests. The Plan denied your request. The Plan says these services are only 
covered by Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has started a new initiative on April 4, 
2022, that will cover up to eight over-the-counter COVID-19 tests each calendar month, at no cost to you. 
Medicare will cover these tests if you have Part B, including those enrolled in a Medicare Advantage plan.  
 
We looked at the file and Medicare rules. The home COVID-19 tests you purchased are covered by Original 
Medicare. The tests must be billed to Medicare and are not payable by the Plan. Based on this information, we 
decided that Medicare rules for coverage of the tests have not been met. Therefore, we decided that the Plan 
does not have to pay for that home COVID-19 tests provided to you on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home therapy services provided on September 28, 2021. 
 
You asked the Plan to pay for the therapy services. The Plan denied your request. The Plan says there is a more 
appropriate code for these 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 97530 is "Therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes". 
 
We find that payment for CPT code 97530 is not supported in the medical record. Specifically, it is 
inappropriate to bill code 97530 for home therapy services. There is a more appropriate code for these services. 
Based on this information, we decided that Medicare rules for coverage of the therapy services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home therapy services provided on 
September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Transcutaneous electrical nerve stimulation (TENS) device 
(E0730) provided on April 4, 2022. 
 
You asked the Plan to pay for the TENS device. You say that this item was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The proof of delivery is not itemized. No tracking 
number was provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a Transcutaneous 
electrical nerve stimulation (TENS) device (E0730) provided on April 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 6, 2022 to April 25, 2022. 
 
You asked the Plan to pay for the services. You say that this was provided due to heart failure. The Plan denied 
your request. The Plan says this was billed with an invalid four-digit Health Insurance Prospective Payment 
System (HIPPS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report skilled nursing facility services with the appropriate HIPPS code. 
 
 
 We find that HIPPS code JIPD is not supported in the medical record. Specifically, this code has four digits. 
HIPPS code must have five digits according to Medicare guidelines. 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 skilled nursing facility (SNF) services provided to the enrollee from April 6, 2022 to April 25, 
2022.