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

 
We decided that the Plan does not have to pay for  a pneumatic compression device (E0676) provided October 
6, 2022. 
 
You asked the Plan to pay for  a pneumatic compression device. You say that the physician prescribed this 
device because they felt i was necessary for the medical safety of the enrollee.  The Plan denied your request. 
The Plan says this service is not a covered benefit under Medicare. 
 
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  a pneumatic compression device (E0676) provided October 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 19, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 18, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from October 25, 2022, to 
December 13, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that you have seen the patient for a long time 
and it would be a hardship for them to find another provider.  The Plan denied your request. The Plan says 
these services are non-covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that billing of the GY modifier indicates that the 
services are non-covered by Medicare statute. These services are excluded from coverage or do not meet the 
definition of any Medicare benefit.  As a result, all claim lines billed with the GY modifier will be 
automatically denied. 
 
In this case, you billed the medical services in dispute with the GY modifier, indicating that the services are non-covered.  Therefore, no payment can be made for these services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the chiropractic services have not been met. Therefore, we decided that the Plan does not have to 
pay for chiropractic services provided from October 25, 2022, to December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
December 21, 2022, and billed with codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 87532, 87563, 
87591, 87661, 87481, 87651, and 87653. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on December 21, 2022, and billed with codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 
87532, 87563, 87591, 87661, 87481, 87651, and 87653.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341-XU, 88342-XU and 88360-XU 
billed for date of service July 27, 2022. 
 You asked the Plan to pay for procedure code(s) 88341-XU, 88342-XU and 88360-XU. You say that you 
believe these services were billed correctly. 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 the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341-XU, 88342-XU 
and 88360-XU. 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) 
88341-XU, 88342-XU and 88360-XU. Based on this information, we decided that Medicare rules for coverage 
of procedure code 88341-XU, 88342-XU and 88360-XU have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code(s) 88341-XU, 88342-XU and 88360-XU billed for date of service 
July 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96375 and J8499 provided on July 9, 2022 
 
You asked the Plan to pay for procedure codes 96375 and J8499. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 96375 
is a column II code to column I code 70487. This claim has not been billed with an appropriate modifier to 
bypass the edit. Additionally, procedure code J8499 is not supported in the medical record. This code has a 
Medically Unlikely Edit (MUE) of 0, which means it is inappropriate to bill this code. 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 codes 96375 and J8499 provided on July 9, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided March 17, 2022, to 
September 23, 2022. 
 
You asked the Plan to pay for the laboratory service . You say that you are requesting payment of the 
laboratory services. The Plan denied your request. The Plan says the claim must be submitted to the primary 
insurance carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another 
payer as the primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for the 
laboratory service until the primary insurer has denied the claim for these services.  Therefore, we decided that 
the Plan does not have to pay for the laboratory services provided March 17, 2022, to September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on June 12, 2022. 
 
You asked the Plan to pay for subsequent hospital care (99232). You say that the necessity of the service 
should be considered, and the claim should be processed for payment. The Plan denied your request. The Plan 
says the incorrect POS of code was 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. 
 
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 find that CPT code 99232 is not supported in the medical record. Specifically, the enrollee was in 
outpatient observation on this date of service, but the inpatient POS code was billed. Based on this information, 
we decided that Medicare rules for coverage of subsequent hospital care (99232) have not been met. Therefore, 
we decided that the Plan does not have to pay for subsequent hospital care (99232) provided on June 12, 2022.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 36556 and 31500. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 76937.  
 
You asked the Plan to pay for testing services provided on August 21, 2022, billed with code 76937. You say 
that the claim was billed correctly and should be paid The Plan says that this procedure code requires modifier 
26. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 36556 and 31500.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 36556 and 31500.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
76937. 
 
The Plan follows 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. 
 
 
 
 
 
 
 
 
 
 
 
 
 We looked at the file, and Medicare rules. In this case, an appropriate modifier to indicate the professional 
component has not been billed with CPT code(s) 76937. Based on this information, we decided that Medicare 
rules for coverage of the services described by procedure code(s) 76937 have not been met. Therefore, we 
decided that the Plan does not have to pay for the services described by procedure code(s) 76937. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing (81479) provided January 4, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please find the appeal information that 
describes the medical necessity of the PrismRa test to inform consideration of payment. The Plan denied your request. The Plan says this is not medically necessary as this test is not FDA approved and based on the 
diagnostic program, MolDX Technical Assessment, the requested PrismRA test is not an approved test. 
 
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 PrismRA testing (81479) provided January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on January 26, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment.  
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code J3490 is included in the global surgery 
payment for procedure code 20610 provided on January 26, 2023. Separate payment cannot be made for 
procedure code J3490. Based on this information, we decided that Medicare rules for coverage of procedure 
code J3490 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
J3490 provided on January 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 28, 2022, to 
February 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have provided the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 28, 2022, to 
February 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 27, 2022, 
to March 24, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 27, 2022, to 
March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0188 for date of service August 17, 2022, 
to September 6, 2022. 
 
You asked the Plan to pay for procedure code E0188. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for procedure code E0188 for date of service August 17, 2022, to 
September 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 2, 2022, to 
May 1, 2022, and from July 31, 2022, to August 24, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have correctly billed the 
services at issue. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 2, 2022, to May 1, 
2022, and from July 31, 2022, to August 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary and 
ordered by a network physician. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023, to January 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (A4595) provided from 
November 22, 2022, to December 22, 2022. 
 
You asked the Plan to pay for electrical stimulator supplies. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that supplies for a TENS unit are included in the 
rental allowance. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of electrical stimulator supplies have not been met. The case record documents that the enrollee was 
provided with a rented TENS unit. There is no separate payment for supplies. Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies (A4595) provided from November 22, 2022, to 
December 22, 2022.