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

 
We decided that the Plan does not have to pay for the panel testing billed for date of service July 19, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 
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.  
 
 The file shows that a urinary tract infection panel was provided. 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 panel testing billed for date of service July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on July 26, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that the supplies are a separately billable expense. 
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 wound care supplies 
provided on July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service February 28, 
2023. 
 
You asked the Plan to pay for the billed testing. You say that each screening service is medically necessary. 
The Plan denied your request. The Plan says the billed code is 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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The medical records show that 
the enrollee has no history of alcohol or drug abuse reported. The records also show there are no side effects, 
no diversion or misuse from the medication. Testing should be based on clinical assessment, including 
medication side effects or inefficacy, suspicious behaviors, or other clinician documented change in affect or 
behavioral pattern. Based on this information, we decided that Medicare rules for coverage of the billed testing 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0483 billed 
for date of service February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307 and G0483 billed for date of service 
May 3, 2023. 
 
You asked the Plan to pay for the billed testing. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed codes are not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80307 and G0483 are not supported in the medical record. The records provided do 
not include lab results for the presumptive and definitive drug testing billed. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 80307 and G0483 billed for date of service May 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle libre 2 continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve a Freestyle libre 2 CGM system. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle libre 2 CGM system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle libre 2 continuous glucose monitor (CGM) system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on June 29, 2023. 
 
You asked the Plan to pay for the nursing facility care. 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 nursing facility care 
provided on June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 80053, 84484, and 85027 billed for date of 
service January 9, 2023. 
 
You asked the Plan to pay for procedure codes 80053, 84484, and 85027. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says this code is included in the facility payment and is 
not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 80053, 84484, and 
85027. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 80053, 
84484, and 85027. Based on this information, we decided that Medicare rules for coverage of procedure code 
80053, 84484, and 85027 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 80053, 84484, and 85027 billed for date of service January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the foot orthotics.  
 
You asked the Plan to reimburse you for the foot orthotics. You say that you have not received reimbursement 
for the orthotics you received. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to reimburse you for the foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 09, 
2023, to May 23, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with 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 $65 
copayment for inpatient hospital care. 
 
You have been asked to pay a $65 copayment for inpatient hospital care. 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. The total amount you owe is $325 ($65 x 5 days = $325). Therefore, we decided that the 
Plan does not have to waive the copayment for inpatient hospital care provided on May 09, 2023, to May 23, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service July 14, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the test informs clinical decision making. 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 billed testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service July 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health aide services provided on March 27, 2023, 
to April 23, 2023.  
 You asked the Plan to pay for the aide services. You say that the services should be reimbursed. The Plan 
denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at the file and the rules. The file does not show that skilled nursing or therapy services were 
provided during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to 
pay for the home health aide services provided on March 27, 2023, to April 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on March 02, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
within the Medicare Part B prescription drugs 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 Medicare Part B prescription drugs provided on March 02, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is not ready to go home 
because they have respiratory failure and needs physical and occupation therapy to maximize their 
independence and endurance. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is improving but still requires acute care services before 
transitioning to a lower level of care. The medical records do not indicate that the enrollee requires services that 
she is not currently receiving but that would be available at the LTACH facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 27, 
2023, to May 30, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with 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 $240 
copayment for inpatient hospital care. 
 
You have been asked to pay a $240 copayment for inpatient hospital care. 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. The total amount you are being asked to pay is $720 ($240 x 3 days = $720). Therefore, 
we decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 27, 
2023, to May 30, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on April 3, 2023, to April 12, 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. You say that that the 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says that  the 
medical records did not have sufficient documentation to clinically validate the diagnosis of A41.9 (sepsis, 
unspecified organism). 
 
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 A41.9 defined as sepsis, unspecified organism. 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 physician reviewer found that the patient meets systemic inflammatory response 
syndrome criteria with a confirmed lung source. Therefore, diagnosis code A 41.9 (sepsis, unspecified 
organism) is supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on April 3, 2023, to April 12, 2023, at the Diagnosis Related Group (DRG) 
originally billed.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital inpatient care (99222) provided on August 
19, 2023. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the service was 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 the evaluation and management service on the 
day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery 
are not included in the global surgery payment for the major surgery and, therefore, may be billed and paid 
separately. CPT code 99222 was billed one the same date as the surgery code which has the 90-day global period but was not billed with modifier -57 to allow separate payment. 
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 27235 
provided on August 19, 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 initial hospital inpatient care 
(99222) provided on August 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 24, 2023. 
 
You asked the Plan to pay for the genetic testing. 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 the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure codes A9277 and A9276. 
 
You asked the Plan to pre-approve procedure codes A9277 and A9276. You say that the items are necessary. 
The Plan denied your request. The Plan says the billed codes are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes A9277 and A9276 have a Status Indicator of N on the Physician Fee Schedule. 
This means that procedure codes A9277 and A9276 are not covered by Medicare. Based on this information, 
we decided that Medicare rules for coverage of procedure codes A9277 and A9276 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve procedure codes A9277 and A9276.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure code E0471-RR-KJ-KX billed for date of service May 23, 
2023. 
 
You asked the Plan to pay for the billed service. You say that payment has been received for previous services 
with the same modifiers. The Plan denied your request. The Plan says that the procedure was billed with a 
modifier that is inappropriate or invalid. 
 
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. 
 
We looked at the file and the rules. The Plan does not provide sufficient rationale regarding the denial for 
services. The Plan does not indicate which modifier was inappropriate/invalid or provide a Medicare citation to 
substantiate their denial. The Medicare rules the Plan includes in the case file pertain to procedure to procedure 
(PTP) edits and the modifiers needed to bypass such edits. However, the Plan does not provide documentation 
to show there is a PTP code pair at issue and that a modifier is required to bypass an edit. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request. Therefore, we decided that the Plan has to pay for procedure code E0471-RR-KJ-KX billed for 
date of service May 23, 2023.  
 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.