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

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service April 2, 
2022. 
 
You asked the Plan to pay for procedure code 99223. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 27, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for procedure code 99223 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99223 billed for date of service 
April 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator you purchased on July 28, 
2022. 
 
You asked the Plan to pay for the portable oxygen concentrator.. You say that you did everything you were 
asked to do by the Plan, so you don't understand why this claim was denied. The Plan denied your request. The 
Plan says Medicare does not cover purchased oxygen equipment and your provider did not order this device for 
you. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. You purchased the oxygen concentrator at 
issue, so it is not covered.  Therefore, we decided that the Plan does not have to pay for the portable oxygen 
concentrator you purchased on July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliances coded E0673 billed for June 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliances coded E0673 billed for June 
23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the continuous positive airway pressure (CPAP) 
device and accessories purchased March 25, 2022. 
 
You asked the Plan to reimburse you for the CPAP device and accessories. You say that you have been unable 
to obtain a CPAP from one of the Plan's vendors because there had been a recall of defective CPAP's. You 
found a used CPAP through an online company and request reimbursement. The Plan denied your request. The 
Plan says the items was purchased from a provider who is not certified with Medicare. If you go to a provider 
who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you 
receive. 
 
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 reimburse you for the continuous positive 
airway pressure (CPAP) device and accessories purchased March 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) 
provided October 24, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that according to the prescription, the 
prescribing physician recommends an extended lifetime use of equipment as they are diagnosed with chronic 
pain and compromised mobility without the option for surgical correction. 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 United States Postal Service (USPS) tracking 
website shows "USPS currently awaiting package." 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 electrical stimulator supplies, 2 lead, per month (A4595) provided October 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0240U billed for date of service September 
7, 2022. 
 
You asked the Plan to pay for procedure code 0240U. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 0240U is bundled into payment for code 87428. 
 
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 0240U is a column II code to column I code 87428 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 0240U billed for date of service September 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on December 14, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test provided on December 14, 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 November 30, 2021. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you bill the 
intermittent pneumatic compression therapy compression sleeves and pump separately for reimbursement and 
are paid all the time from carriers separately. 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. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided 
November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on November 4, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says anesthesia codes are paid to anesthesia providers only. 
 
The Plan must follow Medicare rules. The rules say that payment for anesthesia services is made to the 
physician who personally performed the entire anesthesia service alone or a qualified nonphysician anesthetist. 
 
We looked at the file and Medicare rules. The file shows that the provider is a urologist and not an anesthesia 
provider. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on 
November 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
September 30, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says the billed codes are invalid for 
Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service September 30, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services (01992-AA-QS-P2) provided on November 1, 
2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the enrollee does not meet coverage guidelines. 
 
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 did not substantiate their denial of why the enrollee does not meet coverage guidelines. Information 
was not provided to show why the code was being denied. Therefore, we decided that the Plan has to pay for 
the anesthesia services (01992-AA-QS-P2) provided on November 1, 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 procedure codes J1644, J2597, and J7050 rendered on 
October 12, 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 claim was not billed appropriately. 
 
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 services have been met. The provider has not sent in any medical records to verify the services that were rendered. Therefore, we decided 
that the Plan does not have to pay for procedure codes J1644, J2597, and J7050 rendered on October 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parenteral nutrition solution (B4189). 
 
You asked the Plan to pre-approve parenteral nutrition solution. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for parenteral 
nutrition solution have not been met. 
 
The Plan must follow Medicare rules. The rules say that parenteral nutrition is considered reasonable and 
necessary when the criteria listed in the Medicare rules section of this letter have been met. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of parenteral nutrition solution have not been met. Therefore, we decided that the Plan does not have 
to pre-approve parenteral nutrition solution (B4189).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 10, 2022. 
 
You asked the Plan to pay for the office visit. You say that 1-12444500256 The Plan denied your request. The 
Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 31575 billed for date of service 
October 24, 2022. 
 
You asked the Plan to pay for procedure codes 99223 and 31575. 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 have not 
been met.  
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (15733) provided on September 26, 2022. Based on this information, we decided 
that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 99223 and 31575 billed for date of service October 24, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing (81455) provided on September 7, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this testing was medically necessary and is 
supported in the medical record. 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 provided no clear reason for denial and has provided 
no evidence or citation to support their reasoning. Therefore, we decided that the Plan has to pay for laboratory 
testing (81455) provided on September 7, 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 the office visit billed with code 99213 rendered on October 
20, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 9, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the office visit billed with code 99213 rendered on October 
20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote physiologic monitoring treatment management 
services, 20 minutes or more (99457) each additional 20 minutes of remote physiologic monitoring treatment 
management services (99458) provided on March 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic services. You say that you are requesting reconsideration and 
payment in full for the remote patient monitoring services for this enrollee. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 remote physiologic monitoring treatment 
management services, 20 minutes or more (99457) each additional 20 minutes of remote physiologic 
monitoring treatment management services (99458) provided on March 23, 2022, by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee joint replacement surgery (27447) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve knee joint replacement surgery to be provided by an OON provider. You 
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
knee joint replacement surgery (27447) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on February 1, 2022. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that the services in dispute were medically 
necessary. The Plan denied your request. The Plan says he standard of care for the evaluation of urinary 
incontinence is urinalysis with urine culture and sensitivity. The Plan also says that the PCR testing is 
considered unproven and not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that urine cultures are only covered for certain medical 
indications  
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 urine PCR panel testing. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found that multiplex PCR is non-
inferior to urine culture for detection and identification of bacteria. Further investigation may show that the 
accuracy and speed of PCR to diagnose urinary tract infection (UTI) can significantly improve patient 
outcomes. The review has determined that the items/services at issue in this case medically reasonable and 
necessary. The criteria for coverage have not been met. 
 
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 urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on February 1, 
2022.