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

 
We decided that the Plan does not have to pay for code 73130, defined as radiologic examination, hand; 
minimum of 3 views, performed on April 23, 2023. 
 
You asked the Plan to pay for 73130. You say that 73130 should be paid as billed because it was medically 
necessary. The Plan denied your request. The Plan says 73130 in denied because it has a status indicator of Q1, 
indicating it is an STV-packaged code, and it was billed on the same claim as code 99284, which has a status 
indicator of V. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are assigned a status 
indicator of Q1. STV-packaged services are not eligible for separate payment when a service with status indicator S, T, or V is reported on the same claim. 
 
We looked at the file and Medicare rules. We confirmed that 73130 has a status indicator of Q1, so it is 
considered an STV-packaged service. We confirmed that 99284 has a status indicator of V and was billed on 
the same claim with the same date of service, April 23, 2023. Therefore, no separate payment is warranted for 
73130. Based on this information, we decided that Medicare rules for coverage of 73130 have not been met. 
Therefore, we decided that the Plan does not have to pay for code 73130, defined as radiologic examination, 
hand; minimum of 3 views, performed on April 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0657). 
 
You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of a PCD 
coded E0652 have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Because the base PCD is not covered, the related accessory is not eligible for coverage. Therefore, 
we decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0657).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility visit provided on March 4, 2023, to 
March 30, 2023, by an OON provider.  
 
You asked the Plan to pay for the nursing facility visit. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance. 
 
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 the nursing facility visit provided on March 4, 
2023, to March 30, 2023, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J7297 billed for May 31, 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 claim was billed with the incorrect revenue code. 
 
The Plan must follow Medicare rules. The rules say that administered drugs must be billed with revenue code 
0636.  
 
We looked at the file and Medicare rules. The file shows that the drug billed with code J7297 was billed with 
revenue code 0250 and not the required 0636 revenue code. Therefore, we decided that the Plan does not have 
to pay for procedure code J7297 billed for May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 31, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on December 14, 2022, billed 
with evaluation and management (EM) code 99232. 
 
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 the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, the requested complete medical records for the date of service in question have not been 
provided for review. Therefore, we decided that the Plan does not have to pay for practitioner services provided 
on December 14, 2022, billed with evaluation and management (EM) code 99232.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 21, 2023, billed with 
procedure code 95957-26. 
 
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 this add-on code was not billed with an 
appropriate primary procedure.  
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 95957 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for practitioner services provided on April 21, 2023, billed with procedure code 95957-26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the cost share for a walker on June 30, 2023. 
 
You asked the Plan to reimburse the cost share for a walker. You say that you should be reimbursed the full 
paid amount. 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 of the cost for Medicare-covered durable medical equipment. The provider billed in the amount of 
$2,071.91. The enrollee seen a non-contracting provider and will not be reimbursed the billed amount.  
 
 
 
 You have been asked to pay the $2,071.91 cost share for a walker. This item/service falls within the durable 
medical equipment (DME) 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. Therefore, we decided that the Plan does not have to reimburse 
the cost share for a walker on June 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on May 10, 2023, to 
May 17, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
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 diagnosis code J96.01. 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 use of diagnosis code J96.01 is not supported by the records provided. Our physician 
reviewer found that the enrollee had a diagnosis of pneumonia, but there was no clinical or laboratory evidence 
of acute respiratory failure with hypoxia. The physician did not document use of accessory muscles, nor altered 
mental status due to hypoxia. There was no administration of high flow oxygen by 5 liter or above or bilevel 
positive airway pressure (BiPaP).  
 
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 the inpatient hospital services provided on May 10, 2023, to May 17, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the OON occupational therapy. You say that the enrollee is a long-term care 
member at your facility and the requested outpatient therapy services are medically necessary.  The Plan denied 
your request. The Plan says there are in-network providers available who can provide the same services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
occupational therapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on April 20, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for an office visit (99214) provided on April 20, 2023, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair with multiple 
power option (K0862) and additional items and accessories (codes E2361, E2311, E2313, E2377, E1007, 
E1028, E0955, E2601, E1012, and E0954).  
You asked the Plan to pre-approve a Group 3 heavy duty power wheelchair and additional items and 
accessories. You say that the documentation provided does document a thorough need for powered mobility 
within the home and power seating for the enrollee. The Plan denied your request. The Plan says the enrollee 
does not have a qualifying diagnosis causing mobility limitation for which a Group 3 power wheelchair is 
medically needed. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 heavy duty power wheelchair with multiple power option (K0862) and additional items and 
accessories (codes E2361, E2311, E2313, E2377, E1007, E1028, E0955, E2601, E1012, and E0954).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the reasonable useful lifetime 
(RUL) of equipment be less than 5 years. The rules also say that replacement due to wear is not covered during 
the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve a replacement power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested device.  
The Plan must follow Medicare rules. The rules say that a power mobility device identified with code K0861 is 
covered for certain indications. 
 
Review of the file shows that the documentation does not show that the enrollee can use the requested group 3 
power wheelchair safely and independently. There are no notes that show the enrollees caregivers cannot 
adequately propel an optimally configured manual wheelchair. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve astigmatism correcting function of intraocular lens 
(IOL). 
 
You asked the Plan to pre-approve astigmatism correcting IOL. You say that this service is eligible for 
coverage under your policy. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that the astigmatism-correcting functionality of an 
IOL does not fall into the benefit category and is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of astigmatism correcting IOL have not been met. Therefore, we decided that the Plan does not have 
to pre-approve astigmatism correcting function of intraocular lens (IOL).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99284) 
provided on May 18, 2023. 
 
You asked the Plan to pay for emergency department services (procedure code 99284). You say that CPT 
99284 is appropriate based on the level of services required. The Plan denied your request. The Plan says the 
CPT 99283 is more appropriate based on the services rendered. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
 
  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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found medical decision making of moderate 
complexity requires 2 out of 3 of multiple diagnoses or management options, a moderate amount and 
complexity of data reviewed and moderate risk of complication. A physical examination and radiographs of the 
left leg were performed. No fracture or dislocation was found, and the enrollee was treated with ibuprofen and 
acetaminophen and discharged in stable condition. The provided records in this case do not document 2 out of 
3 of multiple diagnoses or management options, a moderate amount and complexity of data reviewed and 
moderate risk of complication. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency department services (procedure code 99284) provided on May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80048 billed for date of service March 14, 
2023. 
 
You asked the Plan to pay for procedure code 80048. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provider at issue has not been correctly identified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 80048 is not supported. Specifically, the identification code reported for the providing 
laboratory on the claim does not match the identification code in the provided medical records. We are unable 
to verify the providing laboratory. Based on this information, we decided that Medicare rules for coverage of 
procedure code 80048 have not been met. 
  Therefore, we decided that the Plan does not have to pay for procedure code 80048 billed for date of service 
March 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 24, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on July 31, 2023. 
 
You asked the Plan to pay for physicians services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physicians services 
provided on July 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided on July 
04, 2023, to July 06, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you feel that you 
should only be billed for one night. 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 $290 
copayment for inpatient hospital care. 
 
You have been asked to pay a $290 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care 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. You have been asked to pay a total of $580 for the inpatient hospital stay ($290 copayment 
x 2 days = $580). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to reduce the copayment for the inpatient hospital stay provided on July 04, 2023, to July 
06, 2023.