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

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service March 29, 
2023.   
You asked the Plan to pay for procedure code 88341. You say that this service was medically necessary. 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 88341 is 13. The MAI value for this code is 3. You billed 15 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service June 7, 2023.  
 You asked the Plan to pay for procedure code 88341. You say that you have provided medical records. 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 88341 is 13. The MAI value for this code is 3. You billed14 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. In fact, you provided no argument at all 
as to why these additional units were provided. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 88341 billed for date of service June 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service March 29, 
2023.  
 
You asked the Plan to pay for procedure code 88377. You say that the testing was ordered to rule out leukemia. 
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 88377 is 5. The MAI value for this code is 3. You billed 11 units of this 
code, exceeding the MUE. There is not sufficient medical evidence to support the excess number of units. 
Based on this information, we decided that Medicare rules for coverage of procedure code 88377 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 88377 billed for date of 
service March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 5, 2023. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on April 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
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).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 7, 2022, to 
November 5, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was submitted on 
October 8, 2022. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 7, 2022. The NOA was not received by the Plan until December 
30, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 7, 2022, to November 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on April 12, 2023, billed with codes 
U0005, 87502, 87503, 87486, 87541, 87581, 87651, & 87798. 
 
You asked the Plan to pay for the lab testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the lab testing billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on April 12, 
2023, billed with codes U0005, 87502, 87503, 87486, 87541, 87581, 87651, & 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 24, 2023, to 
January 28, 2023, billed with evaluation and management (EM) code 99233. 
 
You asked the Plan to pay for the practitioner services provided . You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code.  
 
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 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 We find that CPT code 99233 is not supported in the medical record. Specifically, no medical records have 
been provided for the dates of service in question. Based on this information, we decided that Medicare rules 
for coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does 
not have to pay for practitioner services provided on January 24, 2023, to January 28, 2023, billed with 
evaluation and management (EM) code 99233.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 9, 2023, to 
January 16, 2023. 
 You asked the Plan to pay for the home health services. You say that the bill type is correct, and all line items 
are covered for this claim. The Plan denied your request. The Plan says the NOA was not received. As such, 
this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from January 9, 
2023, to January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the back brace provided on February 28, 
2023. 
 
You asked the Plan to waive the coinsurance for the back brace. You say that you were unaware of the cost 
share. 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 50% 
coinsurance for out-of-network durable medical equipment and related supplies. 
 
You have been asked to pay 50% coinsurance for the back brace. This item/service falls within the out-of-
network durable medical equipment and related supplies 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. The total you owe is $519.69 ($1,039.37 allowed amount x 
50% = $519.68). Therefore, we decided that the Plan does not have to waive the coinsurance for the back brace 
provided on February 28, 2023.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet all the requirements. The Plan 
says that the services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 3, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are asking the Plan to reconsider the denied 
services as you were not aware the enrollee was covered by Aetna Medicare. The Plan denied your request. 
The Plan says there was no valid authorization for the service. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 an office visit provided on May 3, 2023, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service May 4, 2023. 
 
You asked the Plan to pay for procedure code 72170. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 72170 is bundled into payment for code 73502.  
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 72170 
is a column II code to column I code 73502. 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 72170 billed for date of service May 4, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Regranex. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has failed to heal despite multiple 
modalities of treatment. You also say that the enrollee is at risk for losing their foot if it cannot be healed. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 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 Regranex.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services rendered on October 23, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the services are included in the hospital's contract rate. 
 
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 looked at the file and Medicare rules. These services should not have been reported separately during an 
inpatient stay. 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 radiology services rendered on October 
23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that the Medicare guidelines are inappropriate in this 
patient's case. The Plan denied your request. The Plan says this does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 27, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have supplied medical records to support 
payment. 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 N30.01 has an Excludes1 note in relation to N39.0. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the lab services have not been met. Therefore, we decided that the Plan does not have to pay 
for lab services provided on February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22010 billed for date of service April 4, 
2023. 
 You asked the Plan to pay for procedure code 22010. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 22010 is bundled into payment for code 22852. 
 
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 22010 
is a column II code to column I code 22852. 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 22010 billed for date of service April 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not meet the requirements. The Plan says 
that the services needed may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27530 for date of service May 25, 2022. 
 
You asked the Plan to pay for procedure code 27530. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 27530 is closed treatment of tibial fracture, proximal 
(plateau); without manipulation. 
 
We find that CPT code 27530 is not supported in the medical record. Specifically, the documentation submitted 
does not include that definitive fracture case was performed on the billed date of service. Of note, the medical 
records indicate to elevate and ice your knee, and the patient was instructed to follow up with another provider 
in the office; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure code 27530 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 27530 for date of service May 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical laparoscopy (50565) provided on September 16, 
2021. 
 
You asked the Plan to pay for the surgical service. You say that this should be reprocessed and paid. The Plan 
denied your request. The Plan says the 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 surgical service was not filed until March 21, 2023. 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 surgical laparoscopy (50565) provided on September 16, 2021.