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

 
We decided that the Plan has to pay for the tumor treatment field therapy device, billed with code E0766, 
provided from June 7, 2022, to September 26, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the 
criteria have not been satisfied. 
 
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 referred for the services provided by a contract provider. The file does not show that the Plan 
provided notice that the services provided would not be covered. Under Medicare rules, this means the services 
provided is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the tumor 
treatment field therapy device, billed with code E0766, provided from June 7, 2022, to 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for October 3, 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 pre-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99222 was related to and billed 
on the same day as minor surgical procedure billed with codes 92928 and 93458. Payment for code 99222 is 
included in the global surgical payment for 92928 and 93458. Therefore, we decided that the Plan does not 
have to pay for procedure code 99222 billed for October 3, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department (ED) services provided on February 19, 
2022, billed with code 99285. 
 
You asked the Plan to pay for the ED services. You say that this should be paid. The Plan denied your request. 
The Plan says that this is incidental to another service. 
 
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's only denial rationale is from the claim denial, which indicated that the 
service is incidental to another service and is not separately payable. However, no evidence of any other service 
for which this service is inclusive was demonstrated. As such, we find that the denial of payment at issue is not 
substantiated. Therefore, we decided that the Plan has to pay for the emergency department (ED) services 
provided on February 19, 2022, billed with code 99285.  
 
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 the outpatient hospital services provided on August 24, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. 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 as 
billed. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
Medicare rules say that the I/OCE edits all outpatient hospital claims. OCE edit 21 is applied when a procedure 
(type T or S) is billed on the same day as an E&M service (type V) without modifier -25 being added to the 
E&M service. We looked at the file and Medicare rules. Code G0463 is type V, an E&M service. It was billed 
on the same date as 36589 which is type T. Modifier -25 was not appended as required. Therefore, we decided 
that the Plan does not have to pay for the outpatient hospital services provided on August 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 2, 
2022. 
 
You asked the Plan to pay for procedure code 97010. The Plan denied your request. The Plan says procedure 
code 97010 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64415, 76942, 99100) provided on August 24, 
2022.  
You asked the Plan to pay for the services. 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. Medicare 
rules also say that providers must report services correctly. Providers must report services with the appropriate 
procedure code. 
 
We looked at the file and Medicare rules. The file includes evidence that codes 64415 and 76942 at issue were 
reimbursed by the Plan on October 13, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for codes 64415 and 76942 have not been met.  
 
We also find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules 
for coverage of code 99100 have not been met. Therefore, we decided that the Plan does not have to pay for the 
services (64415, 76942, 99100) provided on August 24, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the services (J7999) provided on December 1, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that payment for this 
service is incidental. 
 
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 argues that payment for this service is incidental. However, the Plan 
has not provided documentation of another code/service provided on the same date. As such, the Plan has not 
shown which service code J7999 is incident to. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the services (J7999) provided on December 1, 
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 oxygen equipment you purchased on October 8, 2022, and 
October 15, 2022. 
 
You asked the Plan to pay for the oxygen equipment. You say that you needed to own a portable oxygen 
system for travel. The Plan denied your request. The Plan says you did not have a prescription for these items 
and did not have prior authorization either. 
 
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 from 
which you purchased this oxygen equipment is not enrolled in the Medicare program. In addition, Medicare 
rules explicitly forbid coverage of purchased oxygen equipment.  Oxygen equipment is only covered as a 
rental. Therefore, we decided that the Plan does not have to pay for oxygen equipment you purchased on 
October 8, 2022, and October 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography provided on November 29, 2022. 
 
You asked the Plan to pay for the echocardiography. You say that you disagree with the Plan's 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 December 9, 2022. Comparison of the two claims shows these are exact duplicates. 
The same service was billed by a different provider; however, both providers specialties are listed as the same 
and bill under the same group. 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 
echocardiography have not been met. Therefore, we decided that the Plan does not have to pay for the 
echocardiography provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for TM-Flow Report (autonomic function testing with an 
ANSAR device (93923, 95923, and 95999) provided on September 8, 2022. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that the autonomic function testing with an ANSAR device 
(coded as 93923, 95923, and 95999) was medically reasonable and necessary for the enrollee in this case. The 
documentation does not support that this testing would impact the management and outcomes in this enrollee. 
The enrollee did not meet the covered indications for autonomic function testing. The enrollee did not meet the 
general indications for non-invasive vascular studies. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for TM-Flow Report (autonomic function testing with an ANSAR device (93923, 95923, and 
95999) provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 3, 2022. 
 
You asked the Plan to pay for the visit. 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 services at issue were reimbursed 
by the Plan on December 30, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the visit have not been met. Therefore, we decided that the 
Plan does not have to pay for the office visit provided on November 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on 
September 29, 2022. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing was deemed 
medically necessary by the treating physician. The Plan denied your request. The Plan says this testing is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. Once this is 
complete, the test is assigned a reimbursement rate and unique test identifier. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing provided on September 
29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 72125, 73030, 73080, 73110, 73140, 93005, 96361, 
and 96374 provided on September 26, 2022. 
 You asked the Plan to pay for codes 72125, 73030, 73080, 73110, 73140, 93005, 96361, and 96374. 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 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 72125, 73030, 73080, 73110, 73140, 93005, 96361, and 96374 are not supported in the 
medical record. Specifically, when a J1 service and a J2 service are reported on the same claim, the single 
payment is based on the rate associated with the J1 service, and the combination of the J1 and J2 services on 
the claim does not make the claim eligible for a complexity adjustment. Code 36556 has a status indicator of 
J1. All other services on this claim are packaged into a simple comprehensive payment. These codes are not 
separately payable as billed. Based on this information, we decided that Medicare rules for coverage of codes 
72125, 73030, 73080, 73110, 73140, 93005, 96361, and 96374 have not been met. Therefore, we decided that 
the Plan does not have to pay for codes 72125, 73030, 73080, 73110, 73140, 93005, 96361, and 96374 
provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99306 provided on April 15, 2022. 
 
You asked the Plan to pay for procedure code 99306. You say that the medical records support the billing of 
code 99306. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99306. 
 
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 99306 is Initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor 
or unit. 
 
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 procedure code 99306. Our reviewer says that the medical 
records do not support the billing of code 99306. Our reviewer found the enrollee was evaluated for wound 
care management. Current Procedural Terminology (CPT) code 99306 25 (1 Unit) was not supported. This 
initial nursing facility care code requires a comprehensive history, a comprehensive examination and medical 
decision making of high complexity. However, the medical records submitted did not support comprehensive 
history and medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99306 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99306 provided on April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20610-LT, 20610-RT, J7324-LT, and 
J7324-RT billed 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with mismatched 
diagnosis codes not appropriate for the billed laterality modifiers. 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 procedure codes 20610-LT, 20610-RT, J7324-LT, and J7324-RT billed for October 31, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (G0402, G0404, G0463) provided on 
September 30, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code G0402, G0404, & G0463 is not supported in the medical record. Specifically, Multiple 
medical visits on the same day 
were reported with the same revenue center without the required G0 condition code. Based on this information, 
we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we 
decided that the Plan does not have to pay for outpatient services (G0402, G0404, G0463) provided on 
September 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Premarin cream. 
 
You asked the Plan to pre-approve Premarin cream. You say that the requested medication is necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested medication is not covered under 
Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Premarin cream.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency services provided on July 1, 2022. 
 
You asked the Plan to pay for the emergency services. You say that these were emergency services that should 
be paid. 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 November 18, 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 emergency services have not been met. 
Therefore, we decided that the Plan does not have to pay for emergency services provided on July 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on June 
27, 2022, to July 20, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says this device is not covered. 
 
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) provided on June 27, 2022, to July 20, 2022.