Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided 
on October 20, 2022. 
 
You asked the Plan to pay for the device. You say that you submitted medical records for review. The Plan 
denied your request. The Plan says this is not covered per the guidelines. 
 The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat 
peripheral artery disease is not eligible for reimbursement. Additionally, the rules state that for equipment to be 
covered, it must be appropriate and needed for use inside the home. 
 
The requested device (E0675) and accessory (E0673) are statutorily not covered by Medicare. Based on this 
information, we decided that Medicare rules for coverage of the device have not been met. Additionally, the 
device was used outside of the home. Therefore, we decided that the Plan does not have to pay for a pneumatic 
compression device (E0673, E0675) provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurostimulator removal by an out-of-network (OON) 
provider. 
 
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 available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
neurostimulator removal by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment services (G2078) provided on October 17, 
2022. 
 
You asked the Plan to pay for opioid treatment services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), 
and Free-Standing Opioid Treatment Program facilities. 
 
We looked at the file and Medicare rules. This service was billed by an individual provider and not by a 
facility. Based on this information, we decided that Medicare rules for coverage of opioid treatment services 
have not been met. Therefore, we decided that the Plan does not have to pay for opioid treatment services 
(G2078) provided on October 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0480) provided on September 27, 2021. 
 
You asked the Plan to pay for the drug testing. You say that this service was medically necessary. 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 drug testing was not filed until October 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 drug testing (G0480) provided on September 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment billed with code G2067 for 
October 31, 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 provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that only an entity enrolled with Medicare as an opioid 
treatment program (OTP) can bill codes G2067-G2075, G2076-G2080, G2215, G2216, and G1028. 
 
We looked at the file and Medicare rules. The file shows that code G2067 was not billed by a provider enrolled 
as an OTP. Therefore, we decided that the Plan does not have to pay for the medication assisted treatment 
billed with code G2067 for October 31, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services billed with codes 0018U and 0245U for 
September 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 that the claim is missing the Dex-Z code. 
 
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. The Plan states that the claim was not billed with the required Dex-Z code and 
references the Palmetto GBA Manual; however, this rule is not binding for the state of Pennsylvania where the 
testing was performed. The Plan has not provided any documentation or binding Medicare rules to support that 
the claim is not payable as billed. Therefore, we decided that the Plan has to pay for the laboratory services 
billed with codes 0018U and 0245U for September 26, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (0241U) provided on December 7, 2022. 
 
You asked the Plan to pay for lab testing. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of lab testing have not 
been met. Therefore, we decided that the Plan does not have to pay for lab testing (0241U) provided on 
December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the foam dressing, sterile pad (A6212, A6209) 
provided from August 15, 2022, to October 29, 2022. 
 
You asked the Plan to reimburse you for the supplies. You say that you need these supplies for treatment of 
your chronic pressure ulcers. The Plan denied your request. The Plan says the provider in this case is not 
certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the foam dressing, sterile pad 
(A6212, A6209) provided from August 15, 2022, to October 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on July 7, 
2022, billed with code 99284. 
 
You asked the Plan to pay for the ED services. You say that this should not be denied as inclusive to any other 
service. The Plan denied your request. The Plan says this cannot be paid on the same date as 51702 without a 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the ED services have been met. Specifically, it appears that payment was made for code 99284 with modifier -25 on August 9, 2022. The file 
shows that a claim with only 99284 was billed on July 18, 2022; however, a claim was already submitted on 
July 13, 2022, with both codes 51702 and 99284-25, both of which were reimbursed. There is no evidence that 
two evaluation and management services were provided on the same date. As such, we find that the denial of 
payment on this claim was appropriate. Therefore, we decided that the Plan does not have to pay for the 
emergency department (ED) services provided on July 7, 2022, billed with code 99284.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the supplies (procedure code A4595) rendered on October 27, 2022. 
 
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. 
The Plan says that there is evidence of misrepresented services. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment (DME) supplies must 
be provided with a proof of delivery. 
 
The required documentation pertaining to the proof of delivery of these supplies was provided. There is a 
packing slip for the date of service, and a proof of delivery for November 2, 2022. Based on this information, 
we decided that Medicare rules for coverage of the supplies have been met. Therefore, we decided that the Plan 
has to pay for the supplies (procedure code A4595) rendered on October 27, 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 segmental 
pneumatic appliance (E0673) provided October 4, 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 
October 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on December 8, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test provided on December 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99283 
for October 28, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that the initial evaluation is always included in the 
allowance for a minor surgical procedure. 
 
We looked at the file and Medicare rules. Procedure code 99283 was related to and billed on the same day as 
minor surgical procedure code 29515. Payment for code 99283 is included in the global surgical payment for 
code 29515. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services 
billed with code 99283 for October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the enrollee for cutting of nails provided on 
April 29, 2022, and August 23, 2022. 
 
You asked the Plan to reimburse the enrollee for cutting of nails. The Plan denied your request. The Plan says 
this service was not to treat any medical condition or diagnosis. Also, the Plan did not receive any receipts or 
itemized bills with your request and nothing showing proof of payment was made. 
 
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 cutting of nails have been met. The file shows you did not provide any receipts, itemized bills or proof of payment. Therefore, we decided that the Plan 
does not have to reimburse the enrollee for cutting of nails provided on April 29, 2022, and August 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service September 
11, 2022. 
 
You asked the Plan to pay for procedure code 88305. You say that this claim has been reviewed by your 
certified specialty coders for accuracy and verified the coding is in accordance with the correct coding 
guidelines. Please have CPT 88305 processed for payment immediately. 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 88305 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 88305 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 88305 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 88305 billed for date of service September 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assay of thyroid stimulating hormone (TSH) (84443) 
provided on October 5, 2021. 
 
You asked the Plan to pay for assay of TSH. You say that you are not in control of when the provider sends 
information. 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 assay of TSH was not filed until December 13, 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 assay of thyroid stimulating hormone (TSH) (84443) provided on October 5, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medication assisted treatment, buprenorphine (oral), (G2068) 
provided on November 21, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the provider is certified by Substance Abuse 
and Mental Health Service Administration (SAMHSA). You also say that this should be reprocessed and paid. 
The Plan denied your request. The Plan says that this claim because it does not meet the opioid treatment 
program criteria for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's rationale is not supported. The rules that the Plan cited do 
not appear to prohibit payment to the program if the prescribing physician is listed on the claim. Therefore, we 
decided that the Plan has to pay for the medication assisted treatment, buprenorphine (oral), (G2068) provided 
on November 21, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on October 25, 
2022. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test has not met Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on October 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on November 10, 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 the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on 
November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided on March 10, 2022, to March 12, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the inpatient care provided on March 10, 2022, to March 12, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transport rendered on November 22, 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 that payment is included in the inpatient hospital facility payment. 
 
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. The Plan states that interfacility ambulance transport is included in the inpatient 
payment; however, the records show that the enrollee was transported from the emergency room (ER) to 
another hospital facility. There is no documentation showing that the enrollee was admitted to inpatient status 
prior to the transport. Therefore, we decided that the Plan has to pay for the ambulance transport rendered on 
November 22, 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.