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

 
We decided that the Plan does not have to pay for diabetic supplies provided on April 21, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that these items were medically necessary. 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 E10.65 has an Excludes1 note in relation to E11.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
diabetic supplies provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99214 
billed for date of service June 9, 2023. 
 
You asked the Plan to pay for 99214. You say that 99214 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99214 is denied because it is not supported in the 
documentation. 
 
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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter.  
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 99214. Our reviewer says that 99214 is not 
supported in the documentation. Our reviewer found the enrollee is a 72-year-old who was seen for right knee 
pain related to osteoarthritis. The documentation from June 9, 2023, showed the enrollee as medically stable 
without complex disease. They received knee injections. The documentation did not include a comprehensive 
history or physical and did not support decision making of moderate complexity. Also, there was no 
documentation detailing the time spent providing these services. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99214 have not been met. Therefore, we decided that the Plan does not have to 
pay for the evaluation and management services coded as 99214 billed for date of service June 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0429, A0425) provided on June 6, 
2023. 
 
You asked the Plan to pay for ambulance services. You say that these services were necessary and were 
reported appropriately. 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 R41.82 has an Excludes1 note in relation to R40.2431. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services (A0429, A0425) provided on June 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88305) provided on April 21, 2023. 
 
You asked the Plan to pay for pathology services. You say that these services are supported in the medical 
record. 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 D12.3 has an Excludes1 note in relation to R63.5. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for pathology services have not been met. Therefore, we decided that the Plan does not have to pay for 
pathology services (88305) provided on April 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (A4239) provided on May 25, 
2023. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that this item was medically necessary. 
The Plan denied your request. The Plan says the records do not support the billed item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain medical records which support the item requested. The record shows no referral to 
the billing supplier for these items. 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 a 
continuous glucose monitor (A4239) provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain pontic (D6240) for tooth #4 and retainer 
crowns (D6740) for teeth #3, #6, #7 and #8. 
 
You asked the Plan to pre-approve a pontic and retainer crowns. You say that this bridge is necessary and 
appropriate. The Plan denied your request. The Plan says these services are not medically necessary and were 
not requested as appropriate services, as a bridge is not possible with the specific codes requested. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a pontic and 
retainer crowns when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a pontic and retainer crowns. Our reviewer says that the dental bridge is not medically necessary or appropriate as requested. Our physician 
reviewer found that you have an existing bridge from teeth #3 to #7. The retainer crowns of the bridge are on 
teeth #3 and #7. You do not have natural teeth #4 and #6, and currently the replacements for these teeth are the 
pontic crowns that are connected to the retainer crowns of teeth #3 and #7. Based on the information provided, 
the procedure codes requested are incorrect. The provider is requesting D6740 (retainer crown) for tooth #6, 
but there is not natural tooth to place a retainer crown onto. The correct code that should be used for this area is 
D6240. Due to this issue, D6240 (pontic-porcelain fused to high noble metal) for tooth #4, and D6740 (retainer 
crown-porcelain/ceramic) for teeth #3,6,7,8 is not medically necessary as the code for tooth #6 is incorrect, and 
the requested bridge would not be suitable for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a pontic and retainer crowns have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a porcelain pontic (D6240) for tooth #4 and retainer crowns (D6740) for 
teeth #3, #6, #7 and #8.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 18, 2023, to 
June 16, 2023. 
 You asked the Plan to pay for the home health services. You say that there was an issue with NOA submission 
with your clearinghouse.  You said that you tried to submit a Request for Anticipated Payment (RAP) instead. 
The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, tthe NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from January 18, 
2023, to June 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 4, 2023, to 
April 2, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you believe the NOA was 
submitted correctly. 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 March 4, 2023, to April 
2, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93005 billed for date of service June 1, 2023. 
 
You asked the Plan to pay for code 93005. You say that this code is separately payable. The Plan denied your 
request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, the code in dispute has a status indicator of QI, meaning 
that it is a STV-packaged service.  This disputed code was billed on the same claim with a code that has a status indicator of S, T, or V.  This means that the code in dispute in this appeal is not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 93005 have not been met. Therefore, we decided that the Plan does not have to pay for code 
93005 billed for date of service June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99233) 
performed on June 20, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level or that 50 minutes 
were spent.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99233) performed on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the morphine sulfate injection (J2274) provided on April 19, 
2023. 
 
You asked the Plan to pay for the morphine sulfate injection (J2274). You say that the attached medical records 
should be reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says the 
billed code and units cannot be verified. 
 
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 J2274 is injection, morphine sulfate, preservative-free for 
epidural or intrathecal use, 10 mg. 
 
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 morphine sulfate injection (J2274). Our reviewer says 
that the service does not meet the criteria for coverage. Our reviewer found that 40 units of procedure code 
cannot be verified. 
 
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 morphine sulfate injection (J2274) have not been met. Therefore, we 
decided that the Plan does not have to pay for the morphine sulfate injection (J2274) provided on April 19, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel provided on June 26, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
provided on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) and a commode 
chair (E0274). 
 
You asked the Plan to pre-approve a total electric hospital bed and a commode chair. You say that the 
requested items are necessary for your daily quality of life. The Plan denied your request. The Plan says the 
requested hospital bed and commode chair are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. The 
rules also say that a commode chair is covered only for enrollees who are confined to a bed or room. 
 
 While a total electric hospital bed and a commode chair may be appropriate in this case, neither the Plan nor 
Medicare offers coverage for this item. The file does not show that you are confined to a bed or room as 
defined by Medicare rules. Therefore, we decided that the Plan does not have to pre-approve a total electric 
hospital bed (E0265) and a commode chair (E0274).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman G5 MIS Fusion Plate. 
 
You asked the Plan to pre-approve the Minuteman G5 MIS Fusion Plate. You say that the procedure is 
medically necessary, as the enrollee has failed more conservative treatments. The Plan denied your request. 
The Plan says that this procedure is considered investigational/experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Minuteman G5 MIS Fusion Plate. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that current evidence-based medical guidelines and peer-reviewed 
literature do not fully support the interspinous fusion device procedure over the "gold standard" of lumbar 
fusion. There is a lack of large-volume, long-term peer-reviewed outcome studies to support the use of this 
device for this enrollees medical condition. The Minuteman G5 is intended for use with bone graft material 
and is not intended for stand-alone use. In addition, fusion indications within guidelines/literature for (existing 
or potential intraoperative) instability have not been documented and/or met in this case. There are multiple 
alternate pain generators plausibly significantly contributing to the clinical condition that have not been fully 
documented as having been excluded and/or ruled out. No compelling rationale is presented, or extenuating 
circumstances noted, to support the medical necessity of this request as an exception. 
 
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 Minuteman G5 MIS Fusion Plate have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Minuteman G5 MIS Fusion Plate.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 4, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services were not related to the 
enrollee's hospice condition. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on May 4, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dupixent Pen. 
 
You asked the Plan to pre-approve the medication. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Dupixent Pen.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (85025 and 80053) billed for date of 
service March 29, 2023. 
 You asked the Plan to pay for laboratory services. You say that these services are supported in the medical 
records. The Plan denied your request. The Plan says the records do not support that the services billed were 
requested by the enrollee's physician or performed by the billing provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, the laboratory order and results indicate that urinalysis was requested and performed. However, 
the services billed were a comprehensive metabolic panel (80053) and a complete blood count (85025). 
Urinalysis is a different service which is reported with a different CPT code. Therefore, we decided that the 
Plan does not have to pay for laboratory services (85025 and 80053) billed for date of service March 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 3, 2022, to 
April 25, 2022. 
 
You asked the Plan to pay for the home health services. 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 the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the home health services have been 
met. In this case, after multiple attempts were made by the Plan, no medical records were provided for review 
to determine if the services were billed correctly. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from April 3, 2022, to April 25, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from July 18, 2023, to August 1, 
2023. 
 
You asked the Plan to pay for the medical services. You say that the patient's hospice enrollment ended on July 
13, 2023. The Plan denied your request. The Plan says Original Medicare is responsible for payment. The Plan says that it will consider payment for date of service August 1, 2023, if it is submitted individually on a bill 
separate from the July dates of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 13, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for medical services provided 
from July 18, 2023, to August 1, 2023.