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

 
We decided that the Plan does not have to pay for the remote monitoring of physiologic parameter(s) (99454), 
remote physiologic monitoring treatment management services, first 20 minutes (99457), and remote 
physiologic monitoring treatment management services, each additional 20 minutes (99458) provided on June 
30, 2022. 
 You asked the Plan to pay for the remote monitoring services. You say that you want these services to be paid. 
The Plan denied your request. The Plan says the services are not medically 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 remote monitoring services. Our 
reviewer says that the remote monitoring services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided documentation does not include any specific clinical rationale 
for the obtained monitoring. Therefore, the reviewer found that the remote monitoring services were not 
medically reasonable or necessary. 
 
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 remote monitoring services have not been met. Therefore, we decided that 
the Plan does not have to pay for the remote monitoring of physiologic parameter(s) (99454), remote 
physiologic monitoring treatment management services, first 20 minutes (99457), and remote physiologic 
monitoring treatment management services, each additional 20 minutes (99458) provided on June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services billed with codes 71045, A4208, A4649, 96361, 
and 96374 for August 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC for code 71045 were not 
performed in different payment localities. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met.  
 
The rules say that payment may not be made by carriers for codes with a PC/TC indicator of 5 when they are 
provided to hospital inpatients or patients in a hospital outpatient department. 
 
The file shows that billed codes 96361 and 96374 have a PC/TC indicator of 5 and were performed in the 
hospital outpatient setting. These codes are not payable in this setting. 
 
The rules say that procedure codes with a status indicator of P are bundled/excluded codes and with a status 
indicator of X are statutorily excluded. 
 
Billed procedure code A4208 has a status indicator of X. This means that this code is statutorily excluded from 
Medicare payment. Code A4649 has a status indicator of P and this means that payment is bundled/excluded. 
 
Therefore, we decided that the Plan does not have to pay for the services billed with codes 71045, A4208, 
A4649, 96361, and 96374 for August 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that this lab testing was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when certain 
criteria are 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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation provided 
to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an 
implantable cardiac monitor (ICM). In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ICM in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (DME) provided to the enrollee 
on March 18, 2022. 
 
You asked the Plan to pay for the DME. 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 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. Medicare rules also say that durable medical equipment (DME) supplies must be provided with a proof of delivery. 
 
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 DME have been met. The provider 
did not submit any proof of delivery for these items for the billed date of service. They cannot be verified, as 
the patient-signed delivery ticket shows a receipt date of August 11, 2022.. Therefore, we decided that the Plan 
does not have to pay for durable medical equipment (DME) provided to the enrollee on March 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with single power 
option (K0856), battery (E2359), positioning accessory (E1028), power tilt system (E1002), back cushion 
(E2620), headrest (E0955), skin protectant seat cushion (E2607). 
 
You asked the Plan to pre-approve a group 3 PWC with single power option and related features and 
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 a group 3 PWC is covered when the criteria listed in 
the Medicare Rules section is 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 a group 3 PWC with single power 
option and related features and accessories. Our reviewer says that these items are not medically necessary. Our 
physician reviewer found the enrollee is not at high risk for skin breakdown, does not require intermittent 
catheterization and does not have significant spasticity. 
 
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 group 3 PWC with single power option and related features and accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power 
wheelchair (PWC) with single power option (K0856), battery (E2359), positioning accessory (E1028), power 
tilt system (E1002), back cushion (E2620), headrest (E0955), skin protectant seat cushion (E2607).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 26, 2022, 
to March 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 26, 2022, to 
March 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
25, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 25, 
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 November 2, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this should be paid for. 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 2 units of this 
code, exceeding the MUE. 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 November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99212) provided on August 30, 2022. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed code is 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 CPT code. 
 
We find that CPT code 99212 is not supported in the medical record. Specifically, the billed service is included 
in the 90 day global surgery period for procedure code 66984, which was billed on June 13 and June 27, 2022. 
Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. 
Therefore, we decided that the Plan does not have to pay for an office visit (99212) provided on August 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service April 26, 
2022. 
 You asked the Plan to pay for procedure code A4550. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code A4550 is 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 code A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4550 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4550 billed for date of service April 26, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services billed with code A0425 for date of service August 
23, 2022. 
 
You asked the Plan to pay for code A0425. You say that this transport was needed to move the patient to a 
different facility. The Plan denied your request. The Plan says that you did not bill the number of units 
properly. 
 
The Plan must follow Medicare rules. Medicare rules say that service codes have Medically Unlikely Edits 
(MUEs), showing the total number of units for that code that should be billed. Some of these MUEs are line-
item edits, and some are date of service edits.  Those codes with a MUE Adjudication Indicator (MAI) of 1 are 
line-item edits, meaning that the total units billed on a single line item cannot exceed the MUE.  
 
In this case, the code in dispute (A0425) has a MAI of 1 and an MUE of 250.  This means that a single line 
item of code A0425 cannot exceed 250 units.  The Plans sole denial rationale is that you incorrectly billed 457 
units of code A0425 on a single line item.  This is not true.  Both your original claim and the medical records 
confirm that you billed 45.7 units, not 457 units, of code A0425.  The number of units billed (45.7) does NOT 
exceed the MUE for this code.  The Plan has provided no other explanation for its denial.  The burden is on the 
Plan to show that its denial was appropriate, and the Plan has failed to meet that burden in this case. Therefore, 
we decided that the Plan has to pay for ambulance services billed with code A0425 for date of service August 
23, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a semi-electric hospital bed (E0260) provided on June 4, 
2022. 
 
You asked the Plan to pay for the semi-electric hospital bed. You say that this equipment was medically 
necessary. The Plan denied your request. The Plan says further payment cannot be made for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers rental of durable medical 
equipment for 13 months. Once the 13th month of rental ends, the supplier must transfer ownership of the 
equipment to the enrollee. 
 
We looked at the file and Medicare rules. 13 months of rental payment was already made for this item. Based 
on this information, we decided that Medicare rules for coverage of the semi-electric hospital bed have not 
been met. Therefore, we decided that the Plan does not have to pay for a semi-electric hospital bed (E0260) 
provided on June 4, 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 October 10, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this is not a duplicate. 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 October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 74018-26 and 74018-26-76 billed for date of service 
September 27, 2022. 
 
You asked the Plan to pay for codes 74018-26 and 74018-26-76. You say that the patient had multiple exams 
on this date of service. 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 October 27, 2022. Comparison of the two claims shows these are exact duplicates. 
Based on this information, we decided that the Medicare rules for codes 74018-26 and 74018-26-76 have not been met. Therefore, we decided that the Plan does not have to pay for codes 74018-26 and 74018-26-76 billed 
for date of service September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service September 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you did not provide a valid order or requisition from the 
ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that for lab services, the lab must be able to supply 
the order for the service billed and medical information supplied to the lab by the ordering provider. In this 
case, you have not provided an order or any documentation from the ordering provider showing why or if the 
lab services in dispute were ordered. Therefore, we decided that the Plan does not have to pay for lab services 
billed for date of service September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 13, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a 
complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00532) provided on October 16, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says a correct claim was needed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 00532 is not supported in the medical record. Specifically, diagnosis code Z79 is not a 
valid primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia 
services (00532) provided on October 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on May 28, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says Medicare does not cover services that are not 
performed by a Medicare-certified provider. 
 
The Plan must follow Medicare rules. Medicare says that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an emergency department visit provided on May 28, 2022.