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

 
We decided that the Plan does not have to pay for lab services provided on July 18, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. 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 July 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided April 27, 
2023, to May 9, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting 
reconsideration based on medical necessity. The Plan denied your request. The Plan says a PCD coded as 
E0675 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 April 27, 2023, to May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service July 24, 
2023.   
You asked the Plan to pay for procedure code 88374. You say that you disagree with the Plan's 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88374 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88374 billed for date of service July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service August 6, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is therefore not payable. 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 81456 billed for date of service August 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 25, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that R11.2 has an Excludes1 note in relation to K92.90. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for 
the services provided on June 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97760 and L0650 billed for July 5, 2023. 
 
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 services are not covered. 
 
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 97760 is orthotic(s) management and training (including 
assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes. 
 
We find that CPT code 97760 is not supported in the medical record. Specifically, there is no documentation of 
orthotics management training. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met.  
 
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. 
 
The file shows that there was no valid proof of delivery supporting that the orthotic billed with code L0650 was 
dispensed. 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 97760 and L0650 billed for July 
5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 for 
April 21, 2023, to May 16, 2023. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device (PCD) coded E0675 for April 21, 2023, to May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110, 91111). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that you are requesting 
reconsideration because the enrollee has a high glucose reading and she is spitting up blood from time to time 
and her labs are elevated. Procedure is medically necessary. Medical records attached to support medical 
necessity. The Plan denied your request. The Plan says the request is not medically necessary because the 
records show the enrollee does not have portal hypertension. Additionally, the enrollee has not had a 
colonoscopy to evaluate for possible colonic sources of gastrointestinal bleeding. 
 
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 pre-approve a wireless capsule endoscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found capsule endoscopy is indicated when an enrollee has signs of acute blood 
loss anemia with negative upper endoscopy and colonoscopy. In this case, the procedure does not appear to be 
medically necessary, and the enrollee does not meet criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a wireless capsule endoscopy (91110, 91111).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 14, 
2023. 
 You asked the Plan to pay for procedure code 76705. You say that this should not be a bundled charge. 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 July 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect test (0012M) provided May 25, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you believe the evidence supporting the use 
of CxBladder Monitor as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says the CX Bladder panel remains unproven at this time. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Cxbladder Detect test (0012M) provided May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that a CardioMEMS device is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says a CardioMEMS device is 
experimental/investigational. 
 
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 pre-approve a CardioMEMS device. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a CardioMEMS device (33289).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 16, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that R19.4 has an Excludes1 note in relation to K59.0. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
services provided on May 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on February 11, 2023, and billed with codes 87798, 87653, 87641, and 87481. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was not medically 
necessary. The Plan denied your request. The Plan says the unbundling of lab codes for PCR panel testing is 
not appropriate.  
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on February 11, 
2023, and billed with codes 87798, 87653, 87641, and 87481.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95941, A4556, A4215, and 95937, billed for 
date of service May 3, 2023. 
 
You asked the Plan to pay for procedure codes 95941, A4556, A4215, and 95937. 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 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. Additionally, code A4556 has a Status Indicator of P 
on the Physician Fee Schedule. This means that code A4556 is bundled, and separate payment cannot be made. 
We also find that code A4215 has a Status Indicator of X under the Physician Fee Schedule. This means that 
code A4215 is not payable. Finally, the claim was not billed with a diagnosis code that supports medical 
necessity for the billed neuromuscular junction testing (95937). Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95941, A4556, A4215, and 95937 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95941, A4556, A4215, and 
95937, billed for date of service May 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (U0003, U0005, G2023) provided on 
March 15, 2023, through April 5, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that multiple claims have denied for being bundle 
when they have been sent correctly. The Plan denied your request. The Plan says this code is included in the 
skilled nursing facility payment and is 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 CPT code.  
The records indicate that this service was provided to the enrollee while a skilled nursing facility (SNF) 
inpatient. All services billed by the SNF (including those furnished under arrangements with an outside 
supplier) for a resident of a SNF in a covered Part A stay are included in the SNF's Part A bill. Payment to you 
for this service is the responsibility of the SNF. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services (U0003, U0005, G2023) provided on March 15, 2023, through April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided January 26, 2022. 
 
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your 
request. The Plan says an Explanation of Benefits (EOB) is needed from the primary insurance company. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan needs the 
primary payer's Explanation of Benefits. As the secondary insurer, the Plan cannot be held responsible for the 
office visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) provided January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on April 3, 2023, and billed with codes 87652, 87798, 87500, 87640, and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the unbundling of lab codes for PCR panel testing is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on April 3, 
2023, and billed with codes 87652, 87798, 87500, 87640, and 87481.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiographies (93350 and 93351), 
use of echocardiographic contrast agent during stress echocardiography (93352), doppler echocardiographies 
(93320 and 93321), and doppler echocardiography color flow velocity mapping (93325). 
 
You asked the Plan to pre-approve the services. You say that you believe a stress echocardiography is 
medically necessary and appropriate for the enrollee. The Plan denied your request. The Plan says  the criteria 
were not met. 
 
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 services. Our physician reviewer 
found there is no documentation that the ECG shows an uninterpretable pattern. There is no evidence provided 
that would support the need for stress echocardiography. In summary, there is insufficient documentation to 
support the medical necessity for the requested stress echocardiography in this enrollee's clinical management. 
 
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 pre-approve transthoracic echocardiographies (93350 and 93351), use of echocardiographic contrast 
agent during stress echocardiography (93352), doppler echocardiographies (93320 and 93321), and doppler 
echocardiography color flow velocity mapping (93325).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 12, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service August 12, 2023.