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

 
We decided that the Plan does not have to pay for procedure code 99417 billed for date of service August 23, 
2022. 
 
You asked the Plan to pay for procedure code 99417. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99417 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99417 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99417 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99417 billed for date of service August 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87481, 87491, 87563, 87640, 87653, 
87798) provided on August 11, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and appropriate. 
The Plan denied your request. The Plan says there is insufficient information provided to support this claim. 
 
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 records provided do not include a physician order to support that these tests were ordered by 
the enrollee's treating physician, and no results were provided to support that these services were reported 
correctly. Therefore, we decided that the Plan does not have to pay for laboratory services (87481, 87491, 
87563, 87640, 87653, 87798) provided on August 11, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from May 30, 2022, through 
June 22, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that it is felt that this claim was billed 
correctly. The Plan denied your request. The Plan says that the number of units of service for revenue code 
0111 are not correct. The hospital stay spans 22 days, but only 21 days were reported on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the unit of service on an institutional claim 
generally refers to the number of days in a given accommodation. The day of admission is counted, while the 
day of discharge is not.  
 
We looked at the file and Medicare rules. The number of days in the date span of this claim is 23 days, not 
counting the discharge date. While only 21 days were reported on revenue code 0111, this only refers to the 
days spent in an inpatient bed. The claim also shows one unit in the revenue code 0450, which indicates one 
day spent in the emergency department, as well as 26 units in revenue code 0762, which denotes the number of 
hours spent in observation care. From this, we conclude that the enrollee spent one day in the emergency 
department, and one day under observation before being admitted to an inpatient bed for the remaining 21 days. 
This means that the number of units reported does match the date span for this hospital stay. Based on this 
information, we decided that Medicare rules for coverage of the inpatient hospital services have been met. 
Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from May 30, 2022, 
through June 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supply allowance (A4595) provided August 9, 2022. 
 
You asked the Plan to pay for the TENS supply allowance. You say that please find attached the requested 
documentation including the medical records, signed durable medical equipment (DME) prescription and 
statement of medical necessity. The Plan denied your request. The Plan says there is evidence of 
misrepresentation. 
 
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 physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the ordering provider's 
office and verified that the provider did not order the DME item. 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) supply allowance (A4595) provided 
August 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 22, 2022, billed with 
codes 75726 and 36247. 
 
You asked the Plan to pay for the services as billed. You say that it is felt that all billed codes should be paid. 
The Plan denied your request. The Plan says the denied codes 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, we have confirmed that code 75726 is a column II code to column I code 37236; however, 75726 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services as billed. Our reviewer says that the records do 
not support the use of modifier -59 to bypass the edit between 75726 and 37236. The records also do not 
support that the services described by 36247 were performed. Our reviewer found the procedure report does not 
include documentation to support modifier -59 as a distinct separate service. When an interventional vascular 
procedure is performed, angiograms and/or venograms are included in the intervention procedure. Therefore, 
modifier -59 cannot be verified in this instance. 
 
Procedure code 36247 is not supported by the medical records submitted. The operative report did not include 
documentation of a selective catheter placement, into the arterial system for the initial third order or more 
selective abdominal, pelvic, or lower extremity artery branch, within a vascular family. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on June 22, 2022, billed with codes 75726 and 36247.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service July 29, 2022 
to July 30, 2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the denial. 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 99291 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 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service July 29, 2022 to July 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97162) provided on August 15, 2022. 
 
You asked the Plan to pay for the therapy services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 97162 is therapy evaluation: moderate complexity, 
requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that 
impact the plan of care; An examination of body systems using standardized tests and measures in addressing a 
total of 3 or more elements from any of the following: body structures and functions, activity limitations, 
and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical 
decision making of moderate complexity using standardized patient assessment instrument and/or measurable 
assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family 
for reimbursement consideration.  
We find that CPT code 97162 is not supported in the medical record. Specifically, the records do not include a 
therapy evaluation for the date of service at issue. Based on this information, we decided that Medicare rules 
for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to 
pay for therapy services (97162) provided on August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0480) provided on September 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and is 
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 (G0480) provided on September 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Diphenhydramine injections (J1200), 
Methylprednisolone injections (codes J2920 and J2930), and Rituximab injections (J9312) provided on March 
3, 2022, and August 31, 2022. 
 
You asked the Plan to waive the coinsurance for the Diphenhydramine injections, Methylprednisolone 
injections, and Rituximab injections. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 You have been asked to pay a 20% coinsurance for the Diphenhydramine injections, Methylprednisolone 
injections, and Rituximab injections. This item/service falls within the Medicare Part B prescription drugs 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the Diphenhydramine injections 
(J1200), Methylprednisolone injections (codes J2920 and J2930), and Rituximab injections (J9312) provided 
on March 3, 2022, and August 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 5, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service November 5, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services provided to the enrollee 
from September 3, 2021, to September 6, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee was treated in the hospital with suspected infection (colitis or duodenitis). Labs revealed 
leukocytosis, elevated lactic acid, elevated Cr (4.17) improved to 3.57 (close to baseline of 3.2-3.3) following 
fluids and antibiotics. Platelets, bilirubin, blood pressure, GCS were each normal and stable. Although it is 
clear this patient had an infection, it was not clear from the documentation that they had 2 or more SOFA to 
meet Sepsis 3 criteria. There was insufficient evidence to show the patient had an inappropriate dysregulated 
response to the infection leading to organ damage/failure. Therefore, the diagnosis of sepsis is not supported. 
DRG of 391 is more appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for acute inpatient hospital services provided to the enrollee from September 3, 2021, to September 6, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for procedures on the lower abdomen (code 00812) provided 
on May 10, 2022. 
 
You asked the Plan to pay for anesthesia for procedures on the lower abdomen. You say that the claim denied 
in error. The Plan denied your request. The Plan says that this is a duplicate claim that has already been 
considered 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 rules also 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. 
 
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 has not provided proof that the claim at issue is a 
duplicate. Therefore, we decided that the Plan has to pay for anesthesia for procedures on the lower abdomen 
(code 00812) provided on May 10, 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 the x-ray provided on February 21, 2022. 
 
You asked the Plan to pay for the x-ray. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $30 copayment for each Medicare-covered x-ray.  
 
The allowable amount for the x-ray service is $22.40. Since this is less than the enrollees $30 copayment 
requirement, the enrollee is responsible for this amount. The enrollee has been asked to pay a $22.40 
copayment for the x-ray. This item/service falls within the outpatient diagnostic tests benefit category. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to pay for the x-ray provided on February 21, 2022.
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 the services are medically necessary for 
the enrollee to receive the care needed. The Plan denied your request. The Plan says the enrollee can safely 
receive this care in another setting, such as a skilled nursing facility or at home with home health services. 
 
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 at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary at this time. 
Completion of treatment at the current facility is recommended. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen system rental (E0431) and an oxygen 
concentrator (E1390). 
 
You asked the Plan to pre-approve a portable oxygen system rental and an oxygen concentrator. You say that 
the services are necessary. The Plan denied your request. The Plan says the enrollee has been using oxygen 
since January 2019. Therefore, she has exceeded the 36 month rental period and will not be eligible for a new 
rental period until January 2024. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no further payment for oxygen 
equipment during the 5-year reasonable useful lifetime (RUL) of the equipment after 36 rental payments have 
been made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable oxygen system rental and an oxygen concentrator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a portable oxygen system rental (E0431) and an oxygen 
concentrator (E1390).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 5, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the rejected service was performed multiple 
times and you are requesting reconsideration of payment on this claim. The Plan denied your request. The Plan 
says the procedure has been billed and allowed the maximum number of times allowed by our payment policy. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the record indicates that the Plan has paid the 
Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed amount as 
payment in full. In this case, the Plan is not responsible for paying the balance that remains after the Medicare 
allowed payment. Therefore, we decided that the Plan does not have to pay for laboratory services provided on 
August 5, 2022.