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

 
We decided that the Plan has to pay for code E0128 billed for date of service January 3, 2023. 
 
You asked the Plan to pay for code E0128. You say that the claim required more than four modifiers, so you 
added the required KX modifier in the claim notes field. The Plan denied your request. The Plan says that you 
did not bill with the required KX modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that the KX modifier is required for wheelchair 
options and accessories to be covered.  However, the rules also say that if a claim requires more than 4 
modifiers, this is indicating by adding modifier 99 to the claim, and then entering any overflow modifiers into 
another area of the claim. 
 
This is precisely the case here.  There were more than 4 modifiers billed on the claim, and you appropriately 
indicated this by appending modifier 99.  The overflow modifiers (which includes the required KX modifier) 
are clearly located in the 'Other Notes- lines 1 and 2 field on the 837 electronic claim.  There is no evidence or 
argument from the Plan that it ever considered this information.  There is no evidence that the Plan even 
acknowledged that these additional modifiers were present.  The burden is on the Plan to show why its denial is 
correct.  By failing to address these overflow modifiers, we find that the Plan has not met this burden. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0128 have been met. Therefore, we decided that the Plan has to pay for code E0128 billed 
for date of service January 3, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dental services on February 14, 2023. 
 
You asked the Plan to waive the coinsurance for dental services. You say that you feel as though the services 
should be covered because you were denied for your dental cleaning. 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 50% 
coinsurance for class 2 basic services for dental services. Class 2 Basic Services. Emergency oral evaluation 
problem focused exams covered once every 12 months. Intra oral X-ray image of the entire mouth (panoramic 
image) covered once every 60 months. Intra oral X-ray image of the entire mouth (full mouth series) covered 
once every 60 months. The provider billed in the amount of $168. Therefore, results in the total cost sharing 
amount of $168. You have been asked to pay a $168 cost share for dental services. This item/service falls within the Medicare 
preferred dental plan benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for dental services on 
February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 screening (0202U) provided on October 30, 
2022. 
 
You asked the Plan to pay for the COVID-19 screening. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this code is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0202U is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 screening have not been met. Specifically, this code is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the COVID-19 screening (0202U) provided on 
October 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 for date of service February 2, 2023. 
 
You asked the Plan to pay for procedure code 71250. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 We find that CPT code 71250 is not payable as billed. Specifically, this code was billed with an outpatient 
place of service. The date of service at issue falls between the admission and discharge date of an inpatient 
confinement. This means the claim is not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of procedure code 71250 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 71250 for date of service February 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 19, 2022, 
to January 17, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. 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 December 19, 2022, to 
January 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
February 11, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you disagree with 
the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $245 
copayment for ambulance services. 
 
You have been asked to pay a $245 copayment for the ambulance transportation. 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 the 
ambulance transportation provided on February 11, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies provided on January 
19, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that records have been submitted to support that 
criteria are met.  The Plan denied your request. The Plan says that the appeal request was not reviwed as the 
Plan missed the time frame for doing so. 
 
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. The Plan has not provided a valid denial rationale in this case. The claim was 
denied for missing records. These records were received in the appeal request. We find that the records do 
support that criteria for the CGM are met. As such, the denial of payment for these supplies is not 
substantiated. Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) 
supplies provided on January 19, 2022.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99285 billed for date of service November 7, 2022. 
 
You asked the Plan to pay for code 99285. You say that the patient had multiple exams on this date of service. 
The Plan denied your request. The Plan says that this claim is a duplicate. 
 
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's sole rationale for denial is that this claim is a duplicate of 
the claim ending in number 6893.  There are several things wrong with this assertion.  First, code 99285 was 
NOT PAID on claim ending in 6893, and the Plan has provided no evidence that code 99285 has been paid on 
any claim.  Second, claim ending in 6893 has a 25 modifier appended to code 99285, and the claim at issue in 
this appeal has no such modifier.  As such, these claims are NOT duplicates.  The addition of the 25 modifier 
indicates that the services were separate and distinct.  The Plan has provided no evidence or explanation 
indicating that the 25 modifier allowing for separate payment was billed incorrectly.  The burden is on the Plan 
to show why its denial is correct.  By failing to address these issues, we find that the Plan has not met its 
burden. Therefore, we decided that the Plan has to pay for code 99285 billed for date of service November 7, 
2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office visit provided on December 9, 2022, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the new patient office visit provided on December 9, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to make additional payment for the surgical services provided on December 2, 
2022, billed with code 63015. 
 
You asked the Plan to make additional payment for the surgical services. You say that it is felt that Medicare 
secondary payment is due for these services.  The Plan denied your request. The Plan says that since another 
payer paid more than the Medicare allowable, the Plan does not have to make payment.  
 
The Plan must follow Medicare rules. Medicare rules say that the amount of Medicare secondary payment is 
calculated using the lowest of the three formulas in the Medicare rules section of this decision.  
 
The Plan has indicated that the Medicare allowable for this service is $1738.55. The results of the three 
calculations are as follows: 
 
1) Billed charge ($30,000) less the amount paid by primary ($8680): $21,320. 
 
2) Medicare allowable charge ($1738) with no cost sharing applicable. 
 
3) As the amount assigned for the primary payment was due to exhaustion of the primary benefits, the primary 
allowable is presumed to be the billed amount. This is because there is no evidence that the provider is legally 
required to accept $8680 as payment in full.  
 
The lowest of the calculations is $1738.55, and this is the amount that is due from the Plan.  Therefore, we 
decided that the Plan has to make additional payment for the surgical services provided on December 2, 2022, 
billed with code 63015.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the pembrolizumab injection provided on 
January 17, 2023, and February 8, 2023. 
 
You asked the Plan to waive the cost sharing for the injections. You say that you feel that these services should 
be covered. 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 20% 
coinsurance for Medicare Part B chemotherapy prescription drugs. 
 
 
 
 You have been asked to pay a $2156.56 coinsurance for the injection provided on January 17, 2023 ($10782.80 
allowed amount x .20 = $2156.56). The Plan is only holding you responsible for a $923.44 coinsurance for the 
injection provided on February 8, 2023, because your out-of-pocket maximum was met partway through the 
20% coinsurance. These items/services fall within the Medicare Part B prescription drugs benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the cost sharing for the pembrolizumab injection provided on January 17, 
2023, and February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 17, 2023. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration stating services were 
rendered to the member due to emergency. 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 office visit provided on 
February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on January 11, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. 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 a nursing facility visit 
provided on January 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 3, 
2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that that Medicare nationally covers NGS testing, 
when the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 3, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
31, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for ambulance services. 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 ambulance services 
provided on October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed with diagnosis codes K82.0 and 
K80.20 provided on October 6, 2022. 
 
You asked the Plan to pay for procedure code 74176. 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. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes K82.0 and K80.20 should not be reported together. Therefore, we decided that the Plan does 
not have to pay for procedure code 74176 billed with diagnosis codes K82.0 and K80.20 provided on October 
6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on January 03, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all patients. 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 home visit for 
evaluation provided on January 03, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance ride provided on September 24, 2022. 
 
You asked the Plan to pay for an ambulance ride. You say that the patient needed to be taken to a specific 
hospital with a specific specialist 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 ambulance ride 
provided on September 24, 2022.