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

 
We decided that the Plan does not have to pay for the radiologic examination (x-ray) of the chest (71045) 
provided on July 12, 2023. 
 You asked the Plan to pay for the x-ray. You say that the service was billed correctly and should be paid. 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 diagnosis code 
R65.10 defined as systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute 
organ dysfunction. 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 the 
radiologic examination (x-ray) of the chest (71045) provided on July 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
September 12, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. 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 urine polymerase chain reaction (PCR) 
panel rendered on September 12, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95938TC, 95911TC, 95886TC and 95940 
billed for date of service June 28, 2023. 
 
You asked the Plan to pay for procedure code(s) 95938TC, 95911TC, 95886TC and 95940. You say that the 
services were billed correctly and should be paid. 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) 95938TC, 95911TC 
and 95886TC. 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) 
95938TC, 95911TC and 95886TC. In addition, we have confirmed that code 95940 is an add-on code for code 
95938, and the primary code was denied payment. Based on this information, we decided that Medicare rules 
for coverage of procedure code 95938TC, 95911TC, 95886TC and 95940 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 95938TC, 95911TC, 95886TC and 95940 
billed for date of service June 28, 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's needs cannot be met at a 
lower level of care. The Plan denied your request. The Plan says the LTACH services are 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 there are no required medical services that are available at the LTACH, that are not 
available at the current health care setting being offered by the health Plan. The requested LTACH services are 
not medically necessary or reasonable for the diagnosis and condition of the enrollee at this time. 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 pay for code 99222 billed for date of service August 21, 2023. 
 
You asked the Plan to pay for code 99222. You say that this service should be paid at the non-contracted rate. 
The Plan denied your request. The Plan says this code is not supported by the medical record. 
 
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 99222 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 moderate level of medical decision making. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, the only medical records you 
provided were from date of service August 22, 2023. The date of service where code 99222 was billed was 
August 21, 2023. You have not supplied any records showing that this code was performed on the date of service billed. Based on this information, we decided that Medicare rules for coverage of code 99222 have not 
been met. Therefore, we decided that the Plan does not have to pay for code 99222 billed for date of service 
August 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need these compression 
stockings. The Plan denied your request. The Plan says the requested compression stockings are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.   
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve CGM. You say that this CGM would help you. The Plan denied your 
request. The Plan says the medical criteria for a CGM have 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.  
Based on this information, we decided that Medicare rules for coverage of CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T2033 billed for date of service October 1, 
2023, to October 7, 2023. 
 
You asked the Plan to pay for procedure code T2033. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 code T2033 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T2033 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code T2033 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T2033 billed for date of service October 1, 2023, to October 7, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95939-TC, 95938-TC, 95927-TC, 95861-
TC, 95868-TC and 95940 billed for date of service February 15, 2023. 
 
You asked the Plan to pay for procedure code(s) 95939-TC, 95938-TC, 95927-TC, 95861-TC, 95868-TC and 
95940. You say that the services were billed correctly and should be paid. 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) 95939-TC, 95938-TC, 
95927-TC, 95861-TC and 95868-TC. 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) 95939-TC, 95938-TC, 95927-TC, 95861-TC, and 95868-TC. In addition, we have confirmed 
that code 95940 is an add-on code for code 95938, and the primary code was denied payment. Based on this 
information, we decided that Medicare rules for coverage of procedure code 95939-TC, 95938-TC, 95927-TC, 
95861-TC, 95868-TC and 95940 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code(s) 95939-TC, 95938-TC, 95927-TC, 95861-TC, 95868-TC and 95940 billed for date of 
service February 15, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 91065 billed for date of service October 4, 
2023.  
 You asked the Plan to pay for procedure code 91065. You say that the service was billed correctly and should 
be paid. 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 91065 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 91065 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 91065 billed for date of service October 4, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an emergency room (ER) visit provided 
from August 4, 2023, to August 5, 2023.  
 
You asked the Plan to waive the deductible for an ER visit. You say that you are on a fixed income and cannot 
afford this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to emergency care services. You have 
been asked to pay $571.18 towards this deductible, as well as an ER copayment ($500 + $71.18 =$571.18). 
 
The item or service you asked the Plan to waive the deductible for falls within the emergency care services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible which applies to emergency care services. This cost sharing is a contractual obligation that had not 
been met at the time an ER visit was received on August 4, 2023, to August 5, 2023. Therefore, we decided 
that the Plan does not have to waive the deductible for an emergency room (ER) visit provided from August 4, 
2023, to August 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 14, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 2, 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 services were not billed correctly. 
 
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 laboratory services rendered on August 2, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95938TC, 95927TC and 95940 billed for 
date of service June 15, 2023. 
 
You asked the Plan to pay for procedure code(s) 95938TC, 95927TC and 95940. You say that the services 
were billed correctly and should be paid. 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) 95938TC and 
95927TC. 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) 95938TC 
and 95927TC. In addition, we have confirmed that code 95940 is an add-on code for code 95938, and the 
primary code was denied payment. Based on this information, we decided that Medicare rules for coverage of 
procedure code 95938TC, 95927TC and 95940 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code(s) 95938TC, 95927TC and 95940 billed for date of service June 15, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency care (99284) provided March 31, 2023. 
 
You asked the Plan to pay for the service. You say that you are requesting reconsideration for services advising 
the coding department has reviewed the services and determined that the claim is coded correctly. The Plan 
denied your request. The Plan says the diagnosis codes should not be reported together which is based on the 
Excludes1 Notes instructions in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Codes R41.82 (Altered mental 
status, unspecified) and R41.0 (Disorientation, unspecified), should not be reported together, per policy, which 
is based on the Excludes1 Notes instructions in the ICD-10-CM Official Guidelines for Coding and Reporting. 
Therefore, we decided that the Plan does not have to pay for the emergency care (99284) provided March 31, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 14, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair van transportation provided on August 27, 2023. 
 
You asked the Plan to pay for the wheelchair van services. You say that the ambulance service should be 
covered. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services. Although the Plan offers a supplemental benefit for non-ambulance transportation, it is only covered 
when transported from a hospital to a skilled nursing facility. 
 
 
  The services you have asked the Plan to pay for are wheelchair van transport services. The documentation 
shows that you were transported from the hospital to your residence. Therefore, we decided that the Plan does 
not have to pay for wheelchair van transportation provided on August 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthosis billed with code L4361 for June 23, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims lines billed with codes without a KX, GA or 
GZ modifier will be rejected as missing information.  
 
We looked at the file and Medicare rules. The file shows that procedure code L4361 was not billed with the 
required KX, GA, or GZ modifier. 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 orthosis 
billed with code L4361 for June 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 18, 
2023, to June 19, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We looked at the file and Medicare rules. There are no medical records for the dates of service at issue to 
support that the criteria for coverage of inpatient hospital services are met. Based on this information, we 
decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we 
decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 18, 2023, to 
June 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72110 billed for August 23, 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 code 72110 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 72110 has an OPPS status indicator of Q1(S) 
and was billed with an emergency room (ER) procedure code, which has an OPPS status indicator of V. Code 
72110 is not separately payable when billed with a code with an OPPS status indicator of V. Therefore, we 
decided that the Plan does not have to pay for procedure code 72110 billed for August 23, 2023.