Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99232) rendered 
from October 13, 2022, to October 16, 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 Current Procedural Terminology (CPT) code 99232-GC (1 Unit) remains 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 99232 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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 vitals were stable, and sepsis 
was not diagnosed. The patient records for these dates included brief histories such as "seen and examined" and 
"still not passed flatus." Physical findings were general and detailed, but not problem-focused. The 
documentation did not support medical decision making of moderate complexity as few changes in clinical 
presentation or test changes were noted on these dates.  
 
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 subsequent hospital care (procedure code 99232) rendered from October 13, 2022, to October 
16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service November 
20, 2022.  
 You asked the Plan to pay for procedure code 99291. You say that you would like the Plan to reconsider their 
denial of payment. 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 99291 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 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service November 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service November 29, 2022. 
 
You asked the Plan to pay for code 99285. You say that the medical records support the code billed. The Plan 
denied your request. The Plan says 99285 is not supported by the medical record. This code was down-coded to 
99284 to reflect the services performed. 
 
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 these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. 
 
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 code 99285. Our reviewer says that code 99285 is not supported by the medical record. Our reviewer found the enrollee was a then 75 year old female with a history 
of cerebrovascular accident, chronic kidney disease Stage IV, Anemia, Factor V Leiden, hypertension, 
hyperlipidemia, irritable bowel syndrome and sickle cell trait. She is maintained on Eliquis therapy. She fell in 
the shower and presented to the emergency room. She was evaluated  and had computed tomography scans of 
the brain and cervical spine. There was no documentation of a comprehensive history and medical decision 
making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99204) rendered on July 17, 
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 documents do not support this level of care. 
 
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 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter." 
 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's history was brief 
and limited. The examination was not detailed, and included an abdominal and chest examination. The 
computed tomography (CT) was concerning for closed loop bowel obstruction and exploratory laparotomy was 
suggested. The patient was otherwise stable. There was insufficient support for decision-making of moderate 
complexity. Also, the note did not clearly show that the encounter was 45-59 minutes in duration. 
 
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 an office visit (procedure code 99204) rendered on July 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis services rendered from November 1, 2022, to 
November 30, 2022. 
 
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 billed services are for more than the allowed treatments. 
 
The Plan must follow Medicare rules. The rules say that, for dialysis sessions that have been furnished 3 times 
(3X) per week, each line should be 90999 without any modifiers appended.  
 
We looked at the file and Medicare rules. The file shows that procedure code 90999 was incorrectly billed with 
modifiers appended. Therefore, we decided that the Plan does not have to pay for the dialysis services rendered 
from November 1, 2022, to November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84155, 814520, 85014, 85018, 85049, 
83735, 84132, 84295, 86001, 80050, 82565, 84443, and 85027 for date of service February 4, 2021. 
 
You asked the Plan to pay for procedure codes 84155, 814520, 85014, 85018, 85049, 83735, 84132, 84295, 
86001, 80050, 82565, 84443, and 85027. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as billed. 
 
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 find that CPT codes 84155, 814520, 85014, 85018, 85049, 83735, 84132, 84295, 86001, 80050, 82565, 
84443, and 85027 are not supported in the medical record. Specifically, the medical records submitted do not 
include a physician order or laboratory requisition for the billed tests. Based on this information, we decided that Medicare rules for coverage of procedure codes 84155, 814520, 85014, 85018, 85049, 83735, 84132, 
84295, 86001, 80050, 82565, 84443, and 85027 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 84155, 814520, 85014, 85018, 85049, 83735, 84132, 84295, 86001, 
80050, 82565, 84443, and 85027 for date of service February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each dialysis treatment provided on 
August 25, 2022, to November 29, 2022. 
 
You asked the Plan to waive the coinsurance for each dialysis treatment. You say that you cannot afford this 
coinsurance. 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 services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for each dialysis treatment. This item/service falls within the services to treat kidney disease 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 for 
each dialysis treatment provided on August 25, 2022, to November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect (0012M) provided December 21, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the evidence supporting the use of Cxbladder 
Detect as a medically necessary diagnostic service is well established and affirmed by Medicare. The Plan 
denied your request. The Plan says the Cxbladder panel remains unproven at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Cxbladder Detect (0012M) provided December 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EpiSwitch Checkpoint inhibitor response test (0332U) 
provided February 21, 2023. 
 You asked the Plan to pay for the genetic testing. You say that you request reconsideration of this clam and 
grant retro-authorization and approve coverage at the allowable rate for the services rendered. The Plan denied 
your request. The Plan says under the Medicare rules this is not a covered benefit because this test has not been 
approved by MolDX as meeting Medicares reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. The Medicare rules say that payment will be made for MolDX 
approved genetic tests which are reasonable and necessary for the diagnosis or management of a disease, and in 
accordance with the test indications published by the provider. This test has not been approved by MolDX as 
meeting Medicares reasonable and necessary requirement. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the EpiSwitch Checkpoint inhibitor response test (0332U) provided February 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service August 27, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for code 
70551. 
 
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service August 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0241U for date of Service February 26, 
2023. 
 
You asked the Plan to pay for procedure code 0241U. You say that you disagree with the Plan's denial. 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 procedure code 0241U 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0241U for date 
of Service February 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the device was medically 
necessary. The Plan denied your request. The Plan says this device is not covered for preventative services. 
 
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 the pneumatic compression device (E0675).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service November 
20, 2022.   
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99285 is 1. The MAI value for this code is 3. You billed 2 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 99285 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99285 billed for date of service November 20, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation services (A0425, A0428) provided on 
October 27, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services are not bundled to a facility 
payment and should be paid separately. The Plan denied your request. The Plan says that the payment for these 
services is included in the payment to the facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no documentation to support that these 
services would be included in the payment to any facility. There is no evidence that the enrollee maintained 
inpatient status with one facility on the date in question or that the enrollee was transported to a different 
building within the same hospital/facility group. These services are not supported as being inpatient 
transportation. The Plan's denial is not substantiated, and these services should be separately payable based on 
the documentation provided. Therefore, we decided that the Plan has to pay for ambulance transportation 
services (A0425, A0428) provided on October 27, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided May 5, 2022 to May 26, 
2022. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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. Many of the records provided were illegible and did not include a 
signature of the ordering physician or a legible date. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of the home health services 
have been met. Therefore, we decided that the Plan does not have to pay for home health services provided 
May 5, 2022 to May 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a vasectomy provided on September 30, 2022. 
 
You asked the Plan to pay for the vasectomy. You say that you had three procedures to remove kidney stones 
and on the third procedure you asked your doctor to also do a vasectomy. The Plan denied your request. The 
Plan says this service is not covered under the members contract under any normal circumstances. 
 
The Plan must follow Medicare rules. Medicare rules say that elective hysterectomy, tubal ligation, and 
vasectomy, if the primary indication for these procedures is sterilization are non-covered conditions. 
 
We looked at the file and Medicare rules. Medicare says a vasectomy, if the primary indication for this 
procedure is sterilization is non-covered. Therefore, we decided that the Plan does not have to pay for a 
vasectomy provided on September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84443, 84479, 84436, and 80053 for date of 
service January 27, 2023. 
 
You asked the Plan to pay for procedure codes 84443, 84479, 84436, and 80053. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 find that CPT codes 84443, 84479, 84436, and 80053 are not supported in the medical record. Specifically,  
these codes were billed with diagnosis codes R46.89 (Other symptoms and signs involving appearance and 
behavior) and F03.90 (Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic 
disturbance, mood disturbance, and anxiety). These diagnosis codes should not be billed together. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 84443, 84479, 84436, and 80053 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 84443, 84479, 
84436, and 80053 for date of service January 27, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual therapy techniques (therapeutic massage services) 
provided on December 15, 2022. 
 
You asked the Plan to pay for therapeutic massage services. You say that the therapeutic massage was 
medically necessary. The Plan denied your request. The Plan says you have exceeded the benefit limit.  
 
The Plan contract covers therapeutic massage services that are limited to six (6) visits per year.  
 
We looked at the file and the Plans rules. The file shows that you have exceeded the benefit limit. Therefore, 
we decided that the Plan does not have to pay for manual therapy techniques (therapeutic massage services) 
provided on December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on January 4, 
2023. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on January 4, 2023.