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

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on July 12, 2023.  
 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 claim was downcoded from CPT 99285 to CPT 99284. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high 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 that the enrollee presented to the 
emergency department with seizure activity. The enrollee was asymptomatic in the emergency room, with a 
normal physical examination. The enrollee was evaluated with computed tomography of the head, blood and 
urine tests and an electrocardiogram which reportedly showed no significant abnormalities. The enrollee was 
evaluated by neurology and treated with an oral dose of Keppra 750 mg and discharged to home. The provided 
records in this case do not document 2 out of 3 of an extensive number of diagnoses or management options, an 
extensive amount and complexity of data reviewed and high 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 room services (procedure code 99285) rendered on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service April 13, 2023, billed with code 99153.  

You asked the Plan to pay for procedure code 99153. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service April 13, 2023, billed 
with code 99153.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on August 
12, 2023, to August 14, 2023. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that you are not responsible for 
this bill, you sent it to your plan. 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 $320 
copayment for inpatient hospital care.  
You have been asked to pay a $320 copayment for an acute inpatient 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 $640 for the inpatient hospital stay ($320 copayment 
x 2 days = $640). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for an acute inpatient stay provided on August 12, 2023, to August 
14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223) 
rendered on June 11, 2023. 
 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 not supported without the required documentation. 
 
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 99223 is "Initial 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, 75 minutes must be met or exceeded." 
 
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 that the documentation supports an 
appropriate history and exam, but not a high level of medical decision making or that at least 75 minutes were 
spent. 
 
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 evaluation and management services (procedure code 99223) rendered on June 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the arthrocentesis, aspiration and/or 
injection (20610) provided on December 28, 2022. 
 
You asked the Plan to reduce the copayment for the arthrocentesis, aspiration and/or injection. You say that this 
procedure was done at the doctor's office, not the hospital. 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 $250 
copay for outpatient hospital services.  
 
You have been asked to pay $242.38, which is less than the standard $250 copayment for the arthrocentesis, 
aspiration and/or injection. This service falls within the outpatient hospital 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 reduce the copayment for the arthrocentesis, aspiration and/or injection (20610) 
provided on December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the continuous glucose monitor supplies 
provided on August 17, 2023. 
 
You asked the Plan to reduce the coinsurance for the continuous glucose monitor supplies. You say that some 
of the items did not work. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the continuous glucose monitor supplies. This item/service 
falls within the 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 amount you owe is $59.34 ($237.38 
allowed amount x 20% = $59.34). Therefore, we decided that the Plan does not have to reduce the coinsurance 
for the continuous glucose monitor supplies provided on August 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 19, 2023, to 
August 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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that all home health prospective payment system (HH PPS) 
claims must be submitted with type of bill (TOB) 0329.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct TOB 
code. 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 the home health services rendered from 
August 19, 2023, to August 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan of extremity veins provided 
on September 14, 2023. 
 
You asked the Plan to waive the copayment for a duplex scan of extremity veins. You say that you do not agree 
with the cost sharing. 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 $130 
copayment for in-network Medicare-covered radiological diagnostic services, including ultrasounds. 
 
You have been asked to pay a $130 copayment for a duplex scan of extremity veins. This item/service falls 
within the in-network Medicare-covered radiological diagnostic services, including ultrasounds 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 $117.17. Therefore, we decided that the 
Plan does not have to waive the copayment for a duplex scan of extremity veins provided on September 14, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for injections provided on August 30, 2023. 
 
You asked the Plan to reduce the copayment for injections. You say that this should not have a surgical 
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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical. 
 
You have been asked to pay a $350 copayment for injections. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical 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 $350. Therefore, we decided that the Plan 
does not have to reduce the copayment for injections provided on August 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on March 29, 
2023, and billed with codes 87500, 87641, 87798, G0452, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 
87661, 87481, 87651, and 87653. 
 
You asked the Plan to pay for the UTI panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing is not covered. 
 
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 urinary tract infection (UTI) panel provided on March 29, 2023, and billed 
with codes 87500, 87641, 87798, G0452, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87661, 87481, 
87651, and 87653.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76830 and 76856 for date of service January 
23, 2023. 
 
You asked the Plan to pay for procedure codes 76830 and 76856. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 28, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for procedure codes 76830 and 76856 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 76830 and 76856 for 
date of service January 23, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from July 25, 2023, 
to August 7, 2023. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment for the services provided from July 25, 2023, to July 31, 2023. The Plan says they would be responsible for payment for the services provided from August 1, 2023, to August 7, 2023, if billed on a 
separate claim submitted to the Plan. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 25, 2023. Original Medicare is responsible for payment 
for the services provided from July 25, 2023, to July 31, 2023. The Plan would be responsible for payment for 
the services provided from August 1, 2023, to August 7, 2023, if billed on a separate claim submitted to the 
Plan. Please submit a separate claim to the Plan for dates of service August 1, 2023, to August 7, 2023, for 
payment reconsideration. Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
services provided from July 25, 2023, to August 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 63030 billed for date of service June 26, 
2023.  
 
You asked the Plan to pay for procedure code 63030. You say that 2 units of 63030 should be paid as billed 
because they are supported in the medical record. The Plan denied your request. The Plan says the number of 
units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 63030 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 63030 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 63030 billed for date of service June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care supplies provided on October 16, 2023.

You asked the Plan to pay for wound care supplies. You say that the items 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 wound care supplies at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the wound care supplies at issue. We found no exception that would require the Plan to pay for the wound care supplies. Therefore, we decided that the Plan does not have to pay for the wound care supplies, provided on October 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Minuteman procedure.

You asked the Plan to pre-approve a Minuteman procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 Minuteman procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found minuteman device and procedure is experimental. More research is needed.

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 Minuteman procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Minuteman procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on May 11, 2023, 
to May 12, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you want to appeal the amount 
being charged. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on May 11, 2023, to May 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance the dental services (D7910, D0220, D1740, and D0140) on April 20, 2023.

You asked the Plan to waive the coinsurance the dental services (D7910, D0220, D1740, and D0140). You say that you would like to request reconsideration for payment. 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 50% coinsurance for Dental Services. 

You have been asked to pay a 50% coinsurance for the dental services (D7910, D0220, D1740, and D0140). This item/service falls within the Dental 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 coinsurance the dental services (D7910, D0220, D1740, and D0140) on April 20, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99284) provided on May 2, 2023. 
 You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the diagnosis code at issue is not appropriate as a primary 
diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code T26.91XA. This 
code is not an appropriate primary diagnosis as the code has a Code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for emergency room services (99284) 
provided on May 2, 2023.