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

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service June 6, 2022. 
 
You asked the Plan to pay for procedure code 99213. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99213 is bundled into 
payment for code 77334. 
 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 99213 
is a column II code to column I code 77334. 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 99213 billed for date of service June 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 17, 2022, to 
August 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. The NOA you submitted lists admission date of August 16, 2022, but the admission date should have 
been August 17, 2022. 
 
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 August 17, 2022, to 
August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided for use during 
surgery on September 14, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was provided for use 
during surgery to prevent thrombotic events. The Plan denied your request. The Plan says this device was 
provided for a non-covered purpose. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service.  
 
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 provided for use during surgery on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until May 24, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on January 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided for use during 
surgery on August 16, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was provided for use 
during surgery to prevent thrombotic events. The Plan denied your request. The Plan says this device was 
provided for a non-covered purpose. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service.  
 
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 provided for use during surgery on August 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76442 billed for date of service October 5, 
2022. 
 
You asked the Plan to pay for procedure code 76442. You say that the claim was billed correctly and 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76442 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 76442 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76442 billed for date of service October 5, 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 August 28, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that according to the enrollee's 
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 the information submitted does not support this level of 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, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the enrollee and 
confirmed that the enrollee had not received any electrical stimulator supplies from this supplier from date of 
service August 28, 2022, of after. 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 August 28, 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 September 
21, 2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the claim was billed correctly and 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 for the HCPCS/CPT code will be denied. 
 
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. 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 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 September 21, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on April 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on April 19, 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 50432 and 99152 provided on June 1, 2022. 
 
You asked the Plan to pay for procedure codes 50432 and 99152. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed 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. 
 
We find that CPT codes 50432 and 99152 are not supported in the medical record. Specifically, the records 
provided do not support the procedure billed. The procedure report provided is not dated for the correct date of 
service. Based on this information, we decided that Medicare rules for coverage of procedure codes 50432 and 
99152 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 50432 
and 99152 provided on June 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on September 21, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. 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. 
 
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 for the supplies provided in this case. 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 durable medical equipment provided on September 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) provided 
to the enrollee on July 26, 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 documents do not support the level of care. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee presented to the 
emergency department following a fall down two stairs, injuring the head, neck, and left foot. The evaluation 
revealed a fracture talus, but was otherwise unremarkable. The enrollee was treated with a wrap and splint. The provided records did not support the use of CPT 99285 in this case as there was not evidence of a need for high 
complexity decision making. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) provided to the enrollee on July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6531 & 
A6549 that were issued on October 8, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that these items were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6531 & 
A6549 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Code A6531 was not billed with a required AW modifier. Therefore, we decided that 
the Plan does not have to pay for the compression stockings identified with code A6531 & A6549 that were 
issued on October 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG); recording in coma or sleep 
only provided to the enrollee on March 29, 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 records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep only." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that this code is not supported as the 
enrollee was not in a coma or sleep. There are more appropriate codes to use in this clinical scenario. (e.g., 
95812 and 95813). 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for electroencephalogram (EEG); recording in coma or sleep only provided to the enrollee on 
March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy provided on February 11, 
2021. 
 
You asked the Plan to pay for the esophagogastroduodenoscopy. You say that you disagree with the Plans 
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 March 1, 2021. 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 esophagogastroduodenoscopy have not 
been met. Therefore, we decided that the Plan does not have to pay for the esophagogastroduodenoscopy 
provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete doppler echocardiography (procedure code 
93320) provided to the enrollee on August 15, 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 Current Procedural Terminology (CPT) code 93320 (1 unit) remains not supported. 
 
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 93320 is "Doppler echocardiography, pulsed wave and/or 
continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); 
complete." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation shows 
evidence of performance of cardiac echocardiography, but not doppler imaging. As such, documentation does 
not support that a complete doppler echocardiogram (procedure code 93320) was performed.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a complete doppler echocardiography (procedure code 93320) provided to the enrollee on 
August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (0037U) provided on December 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim should be covered. The Plan denied your 
request. The Plan says this appeal was not filed timely. 
 
The Plan follows Medicare rules. The rules say that level 1 appeal requests must be filed with 60 calendar days 
from the date of the notice of the initial determination. 
 
The record shows that a claim for the lab services was not filed until August 15, 2022. The initial determination 
was dated March 31, 2022. This means that more than 60 calendar days passed since the initial determination 
was issued. Therefore, we decided that the Plan does not have to pay for the lab services (0037U) provided on 
December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the intermittent limb compression device and appliances received on 
October 25, 2022. 
 
You asked the Plan to pay for the intermittent limb compression device and appliances. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says that the items received are not 
covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the intermittent limb compression device and appliances by a contract provider. The file 
does not show that the Plan provided notice that the intermittent limb compression device and appliances 
would not be covered. Under Medicare rules, this means the intermittent limb compression device and 
appliances is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
intermittent limb compression device and appliances received on October 25, 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 pneumatic compression device (E0675) and appliance 
(E0673) provided from June 16, 2022, to July 6, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
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 appliance (E0673) provided from June 16, 2022, to July 
6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of a modality to 1 or more areas coded 97016 
provided on July 27, 2022. 
 
You asked the Plan to pay for the application of a modality to 1 or more areas. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 97016 is application of a modality to 1 or more areas; 
vasopneumatic devices. 
 
 
 We find that CPT code 97016 is not supported in the medical record. Specifically, the submitted medical 
records do not include the documentation to support that application of a modality to 1 or more areas, 
vasopneumatic devices was performed. Based on this information, we decided that Medicare rules for coverage 
of the application of a modality to 1 or more areas have not been met. Therefore, we decided that the Plan does 
not have to pay for the application of a modality to 1 or more areas coded 97016 provided on July 27, 2022.