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

 
We decided that the Plan does not have to pay for an office visit with podiatry biopsys provided on August 22, 
2023. 
 
You asked the Plan to pay for an office visit with podiatry biopsys. You say that this was medically necessary 
and 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 an office visit with 
podiatry biopsys provided on August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on May 17, 2023. 
 
You asked the Plan to pay for the office visit (99214). You say that the service was medically necessary. 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 office visit (99214) 
provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 9, 2023. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on June 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 23, 2023, billed with 
procedure code 99222-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an inappropriate 
modifier. 
 
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 code 99222-25 is not supported in the medical record. Specifically, it is not appropriate to 
report modifier 25 with a major surgery. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on June 23, 2023, billed with procedure code 99222-25.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing billed with code 0037U for date of service July 
21, 2023. 
 
You asked the Plan to pay for the testing billed with code 0037U. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0037U is only covered when billed with a 
covered diagnosis code. 
 
We looked at the file and Medicare rules. Review of the file shows that code 0037U was billed with diagnosis 
C79.9, defined as secondary malignant neoplasm, site unspecified. This diagnosis code is not listed as a 
covered diagnosis for this service. Based on this information, we decided that Medicare rules for coverage of 
the testing billed with code 0037U have not been met. Therefore, we decided that the Plan does not have to pay 
for the testing billed with code 0037U for date of service July 21, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service August 25, 
2023.  
 
You asked the Plan to pay for procedure code A0425. 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 when an MUE has an MAI of 1, units in excess of the 
MUE are only payable when reported on a separate claim line with appropriate use of a modifier.   
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 345 units of 
this code, exceeding the MUE. The units in excess of the MUE were not reported on a separate claim line with 
an appropriate modifier as required. Based on this information, we decided that Medicare rules for coverage of 
procedure code A0425 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A0425 billed for date of service August 25, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomographicangiography (71275) provided on 
July 24, 2023. 
 
You asked the Plan to pay for the computed tomographicangiography (71275). You say that the service was 
medically necessary. 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 computed 
tomographicangiography (71275) provided on July 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73020 billed for date of service July 14, 
2023. 
 You asked the Plan to pay for procedure code 73020. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 73020 is bundled into payment for code 
73030. 
 
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 73020 
is a column II code to column I code 73030 which was paid on another claim. This claim has not been billed 
with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 73020 billed for 
date of service July 14, 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 July 15, 2022, 
through July 19, 2022, at the Diagnosis Related Group (DRG) 871 originally billed. 
 
You asked the Plan to pay for the acute inpatient hospital care at DRG 871. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the DRG as 
billed has been downgraded. The enrollee did not have sepsis or metabolic encephalopathy as indicated 
diagnoses. 
 
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 diagnosis code A41.9 as defined by sepsis and 
G93.41 as defined by metabolic encephalopathy. 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 871 originally billed. Our reviewer says that the inpatient hospital 
care provided was not billed correctly. Our physician reviewer found that the enrollee was admitted and treated 
in the hospital for otitis media. The computed tomography (CT) showed no mastoiditis or other acute findings. 
He was started on antibiotics and fluids. The workup revealed that the enrollee was at their mental status 
baseline, there was no hypotension, no hypoxia, normal creatinine, normal bilirubin, normal platelet count, and 
no oliguria. Sepsis-3 criteria was not met as there was insufficient evidence to support organ failure due to a 
dysregulated response directly related to systemic infection. Additionally, the enrollees mental status remained 
at baseline. Therefore, the diagnosis code A41.9 (sepsis) and G92.41 (metabolic encephalopathy) are not 
supported for this admission. The documentation provided supports DRG 071.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the acute inpatient hospital care provided from July 15, 2022, through July 19, 2022, at the Diagnosis 
Related Group (DRG) 871 originally billed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45378 billed for date of service July 30, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the diagnosis code is listed as payable. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that certain diagnosis codes have an Excludes1 note which lists 
other diagnosis codes with which they cannot be reported.  In this case, we have confirmed that K62.5 has an Excludes1 note in relation to K92.1. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the billed service have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 45378 billed for date of service July 30, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic interview (90792) provided on 
July 07, 2023. 
 
You asked the Plan to pay for the psychiatric diagnostic interview (90792). You say that the service was 
medically necessary. 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 psychiatric 
diagnostic interview (90792) provided on July 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walking boot (L4361) provided on June 6, 2023. 
 
You asked the Plan to pay for a walking boot. You say that you have billed the item at issue correctly. 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 suppliers must add a KX modifier to the 
AFO/KAFO base and addition codes if all of the coverage criteria in the related LCD have been met.  Claim 
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. Based on this information, we decided that Medicare rules for 
coverage of a walking boot have not been met. Specifically, the item at issue has not been billed with a KX, 
GA or GZ modifier. Therefore, we decided that the Plan does not have to pay for a walking boot (L4361) 
provided on June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service July 2, 2023. 
 
You asked the Plan to pay for the billed service. You say that the diagnosis code is listed as payable. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  In this case, we have confirmed that diagnosis code group J44 has an Excludes1 note in relation to diagnosis 
code group J43. This means that diagnosis codes J44.1 and J43.9 cannot be reported together. Based on this 
information, we decided that the Medicare billing rules for the billed service have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99233 billed for date of service July 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
May 10, 2023. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. The Plan denied your request. The Plan says 
procedure codes 20930 and 20936 is considered bundled and not separately payable.  
 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 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
May 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 28, 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 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 these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
August 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 6, 2022, to 
August 9, 2022, 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 the 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says 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 the sepsis-3 criteria was not met as there were insufficient 
evidence to support the patient had organ failure directly related to a dysregulated response to systemic 
infection. Therefore, code A41.9 (sepsis) is not supported.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 6, 2022, to August 9, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 for date of service July 12, 2023. 
 
You asked the Plan to pay for procedure code 99204. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the documentation shows 
that the enrollee had previous professional claims for this tax identification number/specialty. This means the enrollee was not a new patient. Code 99204 is not supported. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99204 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99204 for date of service July 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ambulance ride provided on 
May 31, 2023. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that you were told that 
this would be covered in full. 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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for an in-network ambulance ride. This item/service falls within 
the ambulance services 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 copayment for an in-
network ambulance ride provided on May 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital inpatient care and hospital inpatient 
discharge billed with codes 99232 and 99239 provided on March 15, 2023, to March 16, 2023. 
 
You asked the Plan to pay for the subsequent hospital inpatient care and hospital discharge. You say that the 
services were billed correctly and should be paid. The Plan denied your request. The Plan says the medical 
records does not have sufficient documentation to support codes 99232 and 99239. 
 
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 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. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. In this case, the CPT Code Manual definition of code 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the subsequent hospital inpatient care and hospital discharge. 
Our reviewer found that the documentation provided does not include a hospital discharge evaluation and 
management note as required to justify code 99239.The documentation does have subsequent hospital care 
notes, but the documentation does not support a moderate level of medical decision-making or any of the 
encounters lasting 35 minutes or more to justify CPT code 99232.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the subsequent 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. When using total time on the date of the encounter for code selection, 35 
minutes must be met or exceeded hospital inpatient or observation discharge day management; more than 30 
minutes on the date of the encounter have not been met. Therefore, we decided that the Plan does not have to 
pay for the subsequent hospital inpatient care and hospital inpatient discharge billed with codes 99232 and 
99239 provided on March 15, 2023, to March 16, 2023.