Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0439 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code G0439. 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 G0439 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 G0439 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0439 billed for date of service March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has had several readmissions to 
the hospital due to chronic hypercapnic respiratory failure. She has severe end stage COPD and Chronic 
Respiratory Failure. Failure to have treatment with a non-invasive ventilator with AVAPS-AE and a guaranteed 
tidal volume will put her at high risk for readmissions to the hospital and life-threatening conditions. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with 
Auto-EPAP (AE) that could be delivered by 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD. ABG 
done during recent hospitalization was consistent with acute on chronic hypercarbic respiratory failure. The 
enrollee may benefit from BiPAP with AVAPS during sleep. This has not been tried or demonstrated to fail as 
an outpatient. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve the requested ventilator. You say that the enrollee requires the use of the 
ventilator. The Plan denied your request. The Plan says the requested ventilator is not necessary as another 
device can provide the respiratory support required. 
 
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 requested ventilator. Our reviewer 
says that the requested ventilator is not medically reasonable and necessary. Our physician reviewer found the 
provided records document that the home ventilator is being requested for use in intelligent volume assured 
pressure support mode with auto-titration (AE) which could be provided by a bilevel positive airway pressure 
(BiPAP) device with average volume assured pressure support and a back-up rate.  
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 requested ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 16, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent or declination date to consultations and the date of consultations in the patients medical record. If 
consultation with the attending or primary care physician is unsuccessful, document the patients medical chart 
with the date and manner of notification to the physician. There was no documented contact with the 
attending/primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator and accessories received on August 
9, 2022. 
 
You asked the Plan to pay for the oxygen concentrator and accessories. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the items received are not a covered benefit when 
received from a non-Medicare enrolled 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 the oxygen concentrator and accessories 
received on August 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 19, 2022, through 
May 18, 2022. 
 
You asked the Plan to pay for home health services. You say that proof of the NOA submission is attached and 
the claim should be reprocessed for payment. The Plan denied your request. The Plan says the claim was 
submitted with the incorrect admission date. 
 
The Plan must follow Medicare rules. Medicare rules say that the admission date on the NOA should match the 
admission date on all subsequent claims.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the claim was submitted with the incorrect 
admission date. Therefore, we decided that the Plan does not have to pay for home health services provided 
from April 19, 2022, through May 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
16, 2022, to May 19, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says there is a lack of supporting clinical evidence 
in the records provided for the DRG and diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 291. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, the documentation does not consistently and completely support the assigned principal 
diagnosis code with DRG. The replacement of DRG is upheld as it is supported by the medical documentation. 
The documentation does not indicate that the diagnostic work-up and treatment ordered by the treating medical 
providers supported a diagnosis code indicating acute on chronic hypoxic respiratory failure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from May 16, 2022, to May 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal x-ray provided on August 11, 2022. 
 
You asked the Plan to pay for the x-ray. You say that the enrollee 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 August 20, 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 the x-ray have not been met. Therefore, we 
decided that the Plan does not have to pay for the abdominal x-ray provided on August 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on August 
29, 2022. 
 
You asked the Plan to pay for the MRI. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the services are 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 70540 is not supported in the medical record. Specifically, all charges, except for 
therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-
based ambulance services are combined and reported under a certain revenue code on a certain type of bill 
code. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. 
Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided 
on August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 14, 2022, billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81291, 81306, 81335, 81355, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 14, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81291, 81306, 81335, 
81355, and 81479.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service July 7, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99285 is bundled into payment for code 99220. 
 
 
 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 99285 
is a column II code to column I code 99220. 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 99285 billed for date of service July 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360 and 88381 billed for date of service 
February 27, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360 and 88381. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says this code is included in 
the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360 and 88381. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360 and 
88381. Based on this information, we decided that Medicare rules for coverage of procedure code 88360 and 
88381 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88360 and 88381 billed for date of service February 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 46200-59 provided on May 20, 
2022. 
 
You asked the Plan to pay for the medical services coded 46200-59. You say that the documentation supports 
the use of the 59 modifier to bypass the NCCI edit. The Plan denied your request. The Plan says payment 
cannot be made for CPT code 46200-59 as this is included in payment to 46200. 
 
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 46200 is a column II code to column I code 46260; however, 46200 
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 medical services coded 46200-59. Our reviewer says that 
the documentation does not support payment for CPT code 46200-59. Our reviewer found that the medical 
records submitted indicate that CPT 46260 - Hemorrhoidectoy, internal and external, 2 or more 
columns/groups was performed and paid by the health plan. There is bundled relationship between CPT 46200 
and 46260. Per NCCI edits policy, a modifier is allowed in order to unbundle to two codes, providing the 
medical records can validate the use of the modifier. In this case, the medical records do not validate that CPT 
46200 was performed as a separate/distinct service, therefore, it is inappropriate to use Modifier 59, and no 
additional reimbursement is allowed. 
 
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 medical services coded 46200-59 have not been met. Therefore, we decided 
that the Plan does not have to pay for the medical services coded 46200-59 provided on May 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9999 billed for date of service February 9, 
2019. 
 
You asked the Plan to pay for procedure code S9999. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is 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 code S9999 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9999 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9999 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9999 billed for date of service February 9, 2019.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0998) provided on July 5, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says ambulance services without transport are non-covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 5, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services (A0998) provided on July 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytogenetics and molecular cytogenetics services 
provided on June 17, 2022.  
You asked the Plan to pay for the cytogenetics and molecular cytogenetics. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the cytogenetics and molecular cytogenetics, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the cytogenetics and molecular cytogenetics services provided on June 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided May 19, 2022, to June 17, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules say that there are certain data requirements for the claim and the 
NOA. 
 
Review of the file shows that the NOA was submitted with an admission date of January 19, 2022. However, 
the claim was submitted with an admission date of March 25, 2021. As the NOA and the claim do not include 
the same admission dates, no payment can be made on this claim. Therefore, we decided that the Plan does not 
have to pay for the home health services provided May 19, 2022, to June 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from June 7, 
2022, to July 6, 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 admit date was reported incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The admit date is in 2021. For enrollees receiving services in 2021 that continue into 2022, the home health 
agency must submit a Notice of Admission (NOA) with a one-time artificial "admission" date corresponding 
the "from" date of the first period of continuing care in 2022. 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 home health services provided to the enrollee from June 7, 2022, to July 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 31, 2022 to March 
1, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs 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 "from" date on the NOA was January 1, 2022. The admit date on the claim (August 4, 2021) 
does not match. Therefore, we decided that the Plan does not have to pay for home health services provided on 
January 31, 2022 to March 1, 2022.