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

 
We decided that the Plan does not have to pay for procedure codes 87481, 87500, 87640, 87652, 87798, 87799, 
and 87900 provided on October 11, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87500, 87640, 87652, 87798, 87799, and 87900. You 
say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan 
says the services are not covered as billed. 
 
The Plan must follow Medicare rules. 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 procedure codes 87481, 87500, 87640, 87652, 87798, 87799, and 87900 provided 
on October 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 26, 2023, and billed with 
codes 87500, 87511, 87640, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the genetic testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
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 genetic testing provided on July 26, 2023, and billed with codes 87500, 
87511, 87640, 87653, 87798, and 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management of an established patient 
provided on August 21, 2023. 
 
You asked the Plan to pay for evaluation and management of an established patient. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 evaluation and management of an established patient provided on August 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on August 24, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
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 supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services described by code 01992 billed for 
date of service December 8, 2022. 
 
You asked the Plan to pay for 01992. You say that 01992 should be paid as billed because it was submitted 
with the same diagnosis code that was used by the surgeon. The Plan denied your request. The Plan says 01992 
is denied because it was billed without the required -QS modifier, and it was billed with a diagnosis code that 
does not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that when MAC is provided and procedure code 
01992 is billed, modifier -QS must be used. The rules also say that diagnosis code M54.16 is not listed as a 
diagnosis code that supports medical necessity when billing procedure code 01992. 
 We looked at the file and Medicare rules. In this case, the medical records contain evidence that MAC was 
provided. We confirmed that procedure code 01992 was billed without modifier -QS. Modifier -QS is required 
when reporting 01992 when MAC is provided. We have also confirmed that procedure code 01992 was billed 
with diagnosis code M54.16, defined as radiculopathy, lumbar region. No additional diagnoses were listed on 
the claim. Per LCA A57361, M54.16 does not support medical necessity when billing 01992. As such, the 
denial of 01992 is appropriate. Based on this information, we decided that Medicare rules for coverage of 
01992 have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services 
described by code 01992 billed for date of service December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on September 
29, 2023. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you were unaware of the 
copayment. 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 $35 
copayment for urgently needed services. 
 
You have been asked to pay a $35 copayment for the urgent care visit. This item/service falls within the 
urgently needed services 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 copayment for the urgent 
care visit provided on September 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the circulating cold pad provided on May 17, 2023, to June 
06, 2023. 
 
You asked the Plan to pay for the circulating cold pad. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 circulating cold pad provided on May 17, 2023, to June 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 15, 2023, billed 
with procedure code 99212. 
 
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 the service at issue was not billed with the 
required modifier to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 99212 
provided on August 8, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on 
August 15, 2023, billed with procedure code 99212.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
August 8, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you request your claim be approved and 
reprocessed at the appropriate rate and at the in-network benefit level. The Plan denied your request. The Plan 
says the claim for this molecular pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 unlisted molecular 
pathology procedure (81479) provided August 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99214 billed for date of service September 15, 2023. 
 
You asked the Plan to pay for 99214. You say that 99214 should be paid as billed because it is supported in the 
medical records. The Plan denied your request. The Plan says the service at issue was not billed with the 
required modifier to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are 
E&M services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated 
surgical procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 48150 
provided on August 8, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management 
services described by code 99214 billed for date of service September 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for an office visit and the laboratory services 
provided on September 11, 2023, and September 26, 2023. 
 
You asked the Plan to reduce the deductible for an office visit and the lab services. You say that you would like 
for these claims to be reprocessed at the in-network benefit level. 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. Your 
contract with the Plan says that there is a $150 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
You have been asked to pay $16.96 towards the deductible for the lab services provided on September 11, 
2023. The item or service you asked the Plan to reduce the deductible for falls within the outpatient diagnostic 
tests and therapeutic services and supplies benefit category. You have also been asked to pay $88.94 towards 
your deductible for the office visit provided on September 26, 2023. The item or service you asked the Plan to 
reduce the deductible for falls within the physician/practitioner services, including doctors office visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 
deductible which applies to physician/practitioner services, including doctors office visits and outpatient 
diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not 
been met at the time an office visit and the lab services was received on September 11, 2023, to September 26, 
2023. Therefore, we decided that the Plan does not have to reduce the deductible for an office visit and the 
laboratory services provided on September 11, 2023, and September 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each the nail debridement procedure 
provided on July 27, 2023, to September 28, 2023. 
 
You asked the Plan to waive the copayment for each the nail debridement procedure. You say that these 
services should be fully covered. 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 $45 
copayment for podiatry services. 
 
You have been asked to pay a $45 copayment for each the nail debridement procedure. This item/service falls 
within the podiatry services 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. However, since the allowed amount is less than the standard copayment, you only owe 
$43.18 for each service. The total amount you owe is $86.36 ($43.18 copayment x 2 procedure = $86.36). 
Therefore, we decided that the Plan does not have to waive the copayment for each the nail debridement 
procedure provided on July 27, 2023, to September 28, 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 5, 
2023, to May 12, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting 
reconsideration based on medical necessity and evidence based medical literature that substantiate the efficacy 
of the treatment rendered. The Plan denied your request. The Plan says a PCD coded as E0675 is excluded 
from coverage under the Medicare DME 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) provided April 5, 2023, to May 12, 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 without the IRF services the enrollee would have to 
return to the hospital and would be a fall risk. The Plan denied your request. The Plan says the IRF services 
requirements have not been met.  
 
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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collagen dressing provided on August 23, 2023. 
 
You asked the Plan to pay for the collagen dressing. You say that you are asking for the review of the 
submitted documents. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 collagen dressing provided on August 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 15, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted the medical 
documentation to support the medical necessity and the claim to be reprocessed and paid. The Plan denied your 
request. The Plan says the provider is not a plan contract provider and is not enrolled in Medicare as a durable 
medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on August 15, 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 the IRF services will allow the enrollee to regain 
their strength. The Plan denied your request. The Plan says the requirements for IRF services have not been 
met.  
 
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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of 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.