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

 
We decided that the Plan does not have to pay for procedure code 88321 billed for date of service March 14, 
2022. 
 
You asked the Plan to pay for procedure code 88321. You say that these services are supported in the medical 
record. 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 88321 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 88321 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88321 billed for date of service March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation (tens) device 
supplies (E0730) provided on September 5, 2022 
 
You asked the Plan to pay for tens device supplies. You say that this was billed correctly. The Plan denied your 
request. The Plan says a proof of delivery has not been submitted 
 
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 proof of 
delivery in the file is for a different date of service. 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 transcutaneous electrical nerve stimulation (tens) device supplies (E0730) provided on September 5, 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 November 
25, 2022. 
 
You asked the Plan to pay for procedure code 76641. 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 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 November 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342 and 88360 billed for date of 
service September 10, 2021. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342 and 88360. You say that these services were 
reported correctly. 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) 88341, 88342 and 
88360. 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) 88341, 
88342 and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342 and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342 and 88360 billed for date of service September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies billed with codes A7000-NU, A7526, A4629, 
A7010-NU, A7525, A4623, A7002-NU, A4628-NU, and A4624-NU for July 26, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 supplies billed with codes A7000-NU, A7526, A4629, 
A7010-NU, A7525, A4623, A7002-NU, A4628-NU, and A4624-NU for July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) billed for date of service July 
21, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service was reported correctly. The Plan denied 
your request. The Plan says the reported code is not supported in the medical records. 
 
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 G0483 is drug test(s), definitive, 22 or more drug 
class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records provided 
support that 19 drug classes were tested in this case, which does not meet the criteria for code G0483 which 
requires testing 22 or more classes. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for definitive drug 
testing (G0483) billed for date of service July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87481, 87640, 87651, 87653 and 87798) 
billed for date of service September 19, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported by the medical records. The Plan denied your request. The Plan says there is insufficient information 
to support that these services were necessary and were ordered by the enrollee's treating physician. 
 
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 laboratory services have been met. 
Specifically, the medical records provided do not include a signed physician order or any medical records or 
notes from the referring provider. Without this information, we cannot verify the intent for this testing to be 
performed, that these services were medically necessary, and that these tests were ordered by a physician who 
is treating the enrollee. Therefore, we decided that the Plan does not have to pay for laboratory services (87481, 
87640, 87651, 87653 and 87798) billed for date of service September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 September 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on August 25, 2022. 
 
You asked the Plan to pay for the 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 covered in this place of 
service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device and appliance was used in an ambulatory surgical center. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliance 
provided on August 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided August 2, 2022. 
 
You asked the Plan to pay for the TENS device. 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 
there is 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 documentation submitted did not include a 
proof of delivery or a delivery ticket. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (TENS) device (E0730) provided August 2, 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 appliance (E0673) provided August 15, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. 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 appliance (E0673) provided August 
15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on August 9, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the items are not payable in this place of service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device and appliance were used in an ambulatory surgical 
center. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and 
appliance provided on August 9, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient surgery provided on August 5, 2022. 
 
You asked the Plan to pay for the outpatient surgery. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that for Bill Types 13X and 76X, we need the device-intensive procedure 
code when billing a device procedure code. If there is not a device-intensive procedure code, we will 
deny this charge. 
 
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. Review of the file shows that the Plan has denied this claim due to "For Bill 
Types 13X and 76X, we need the device-intensive procedure code when billing a device procedure code. If 
there isnt a device-intensive procedure code, we will deny this charge". No additional explanation was 
provided on why this claim is not payable as billed. No Medicare rules were provided to support this denial. No 
other denial rationale was provided. The Plan did not substantiate their denial. Therefore, we decided that the 
Plan has to pay for the outpatient surgery provided on August 5, 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 codes 95886, 95955, and 95907 provided on August 15, 
2022. 
 
You asked the Plan to pay for codes 95886, 95955, and 95907. 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. 
 
We find that CPT codes 95886, 95955, and 95907 are not supported in the medical record. Specifically, The 
technical report did not include documentation of a complete needle electromyography, per each extremity with 
related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; 
for five or more muscles studied, innervated by three or more nerves or four or more spinal levels (listed 
separately in addition to code for primary procedure); therefore, code 95886 cannot be verified. The technical report did not include documentation of an electroencephalogram (EEG) during nonintracranial 
surgery (carotid surgery); therefore, code 95955 cannot be verified. 
 
The technical report did not include documentation of nerve conduction studies, for 1-2 studies; therefore, code 
95907 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of codes 95886, 95955, and 95907 
have not been met. Therefore, we decided that the Plan does not have to pay for codes 95886, 95955, and 
95907 provided on August 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for date of service March 9, 
2022. 
 
You asked the Plan to pay for procedure code 94761. You say that you disagree with the Plan's 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 94761 has a Status Indicator of T on the Physician Fee Schedule. Review of the 
file shows that other services are payable under the physician fee schedule are billed on the same date by the 
same provider. This means that procedure code 94761 is bundled into the physician services for which payment 
is made. Based on this information, we decided that Medicare rules for coverage of procedure code 94761 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 94761 billed for 
date of service March 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Keytruda is indicated for the treatment 
of head and neck cancer (squamous cell) until disease progression or for up to 24 months in patients without 
progression. The Medicare-approved major drug compendia do not support the use of Keytruda beyond 24 
months for the treatment of head and neck cancer (squamous cell). The services are therefore not reasonable or 
medically necessary and safe and effective for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF services requested are medically necessary. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on August 2, 2021, 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says 
according to Medicare guidelines an original claim submission must be filed to the appropriate Medicare 
claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were 
furnished. 
 
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 emergency department visit was not filed until September 1, 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 an emergency department visit provided on 
August 2, 2021,
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The health 
plan has approved ongoing care in the current acute care setting. 
 
 
  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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.