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

 
We decided that the Plan does not have to pay for the wound care supplies coded as A6216, A6402, A6252 and 
A4452 provided on April 6,2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the wound care supplies. You say that the claim denied that you are out of 
network which is not an accurate statement. Please reprocess the claim for payment. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the wound care supplies coded as A6216, A6402, 
A6252 and A4452 provided on April 6,2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80053, 80061, 82306, 82607, 82746, 
83880, 84443, 85025) provided on April 25, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that this claim should be covered. The Plan 
denied your request. The Plan says these services are not covered when provided OON. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (80053, 80061, 82306, 
82607, 82746, 83880, 84443, 85025) provided on April 25, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service February 6, 
2023.  
 
You asked the Plan to pay for procedure code 87798. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says this code is not supported for separate billing. 
 
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 87798 is a column II code to column I code 87801; however, 87798 
was billed with a modifier.  
 
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 procedure code 87798. Our reviewer says that the XU 
modifier is not supported with code 87798. Our reviewer found the record shows that 87798 is part of 87801 
and should not be reported separately with modifier XU. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87798 billed for date of service February 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99284, 36000, 81003, 80053, 
85025) provided on April 21, 2023. 
 
You asked the Plan to pay for emergency room services. You say that you are requesting reconsideration for 
the denied services. The Plan denied your request. The Plan says code E08.65 is a manifestation diagnosis with 
a code first note, therefore, the underlying condition should be sequenced first. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must comply with ICD-10-CM Coding 
guidelines. The guidelines state that a manifestation code is not appropriate as a primary diagnosis as the 
etiology should be sequenced first.  
 We looked at your request, the file and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of emergency room services have not been met. Specifically, this claim was billed with 
primary diagnosis code E08.65.  Diagnosis code E08.65 has a "code first" note in the ICD-10 Manual. This 
means that it cannot be used as a primary diagnosis. Therefore, we decided that the Plan does not have to pay 
for emergency room services (99284, 36000, 81003, 80053, 85025) provided on April 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on February 7, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99285. 
 
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 procedure code 99285. Our reviewer says that the medical 
records do not support the billing of code 99285. Our reviewer found the enrollee presented to the emergency 
department on February 7, 2023, with bilateral hip and bilateral leg pain which has been ongoing for months. 
Documentation from an encounter from that date included an appropriate history and physical. Vitals were 
stable, electrocardiogram (ECG) was normal. He was diagnosed with Osteoarthritis (OA) and Peripheral 
Arterial Disease (PAD) causing symptoms and suggested no change in treatment (was already on pain 
medication). The documentation did not sufficiently support a high level of decision making to justify the code, 
99285.  
 
We looked at this coder's review, the file, and Medicare rules. 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 provided on February 7, 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 enrollee will benefit from a course of inpatient 
acute level rehabilitation for comprehensive prosthetic training with multidisciplinary services from physical, 
occupational and recreational therapists as well as psychological counseling and regular medical management 
by nursing and physician staff. The Plan denied your request. The Plan says the service requested is not 
supported based on the records received. 
 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fees associated with your lodging provided on September 
2, 2021, to January 8, 2022. 
 
You asked the Plan to pay for the fees associated with your lodging. You say that the receipts provided support 
the reimbursement being requested. The Plan denied your request. The Plan says these are non-covered 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that when a Plan has to provide transplant services at 
a more distant location, they must also provide reasonable transportation to the distant facility and reasonable 
accommodations for the enrollee and a companion.  
 
We looked at the file and Medicare rules. Administration and applications fees for apartments, security 
deposits, trash fees, resident insurance fees, pest fees, and water/sewer fees are not considered part of 
reasonable accommodations. The Plan has demonstrated that they reimbursed you the cost of rent for 
September 2021 through January 2022. This encompassed their responsibility for reasonable accommodations 
during your transplant treatment at a distant location. Therefore, we decided that the Plan does not have to pay 
for the fees associated with your lodging provided on September 2, 2021, to January 8, 2022, (and billed under 
claim number ending in 4434).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87799 billed for date of service February 13, 
2023. 
 
You asked the Plan to pay for procedure code 87799. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says this code is not supported for separate 
payment. 
 
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 87799 is a column II code to column I code 87798; however, 87799 
was billed with a modifier.  
 
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 procedure code 87799. Our reviewer says that this code is 
not supported as billed. Our reviewer found the documentation does not support that this procedure code is a 
distinct procedural service from the primary procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87799 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87799 billed for date of service February 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service June 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was ordered due to the patient's 
diagnosis. 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 lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed for date of service 
June 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance (eg, proton) imaging (MRI), spinal 
canal and contents, lumbar; without contrast material (72148) provided on September 16, 2022. 
 
You asked the Plan to pay for the MRI. You say that the claim should be paid. The Plan denied your request. 
The Plan says this service was paid on a claim and no additional information was provided to verify two 
separate tests were done for the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the MRI have been met. Review of the 
records submitted do not indicate that two separate services were performed/supported. The medical records 
provided by the appellant only show magnetic resonance imaging (MRI) for a September 19, 2022, date of 
service. The date of service appealed is for September 16, 2022. Code 72148-26 was billed for September 16, 
2022, and was paid on October 20, 2022. Therefore, we decided that the Plan does not have to pay for the 
magnetic resonance (eg, proton) imaging (MRI), spinal canal and contents, lumbar; without contrast material 
(72148) provided on September 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes U0004 and U0005 billed for date of service 
January 4, 2023.  
 
You asked the Plan to pay for procedure codes U0004 and U0005. 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 U0004 is 2. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. The MUE for CPT code U0005 is 1. The MAI value for this code is 3. You billed 4 
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 U0004 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes U0004 and U0005 billed for date of service 
January 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 6 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 6 months. 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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 ventilator for 6 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found continuation of a home 
ventilator is not medically necessary. This enrollee has had a home ventilator since 2020, prescribed following 
a hospitalization for acute on chronic hypercarbic respiratory failure. The ventilator is being used in the average 
volume-assured pressure supportautomated expiratory (AVAPS-AE) mode. This mode can be provided with 
bilevel positive airway pressure (BiPAP); BiPAP with average volume assured pressure support (AVAPS) has 
not been tried as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. Alarms and battery backup are not medically necessary. 
 
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 ventilator for 6 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 6 months (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that when two power seating 
functions/actuators/motors are provided, one unit of E2311 is allowed. The Plan denied your request. The Plan 
says there is not a medical need to control power options through the joystick. 
 
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 an electronic connection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has impaired mobility because they have limited knee function. Per the 
doctor's note the enrollee does not have impairment in their upper extremities. Our reviewer found that the 
functional assessment indicates the enrollee is able to feed themselves. Our physician reviewer also found that 
the enrollee has sufficient strength and function in upper extremities to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 20, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services should be covered. 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 laboratory 
services provided on March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on February 17, 2023. 
 
You asked the Plan to pay for the Cxbladder 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 test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0481) provided on July 12, 2022.  
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 G0481 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Review of the file shows that the medical 
records do not contain an order that specifically list what test(s) are to be performed in the custom panel. Based 
on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing (G0481) provided on July 12, 2022.