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

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service September 
15, 2022. 
 
You asked the Plan to pay for procedure code(s) 88305. You say that this service was 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) 88305. 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) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service September 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 99152 and 99153 for date of service August 
4, 2022. 
 
You asked the Plan to pay for procedure codes 99152 and 99153. 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. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation does not 
indicate the presence of an independent trained observer for the billed services. Therefore, code 99152 is not 
supported. In this case, we have confirmed that code 99153 is an add-on code and has not been billed with an 
appropriate primary procedure code. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 99152 and 99153 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 99152 and 99153 for date of service August 4, 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 13, 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 
13, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on November 30, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you were visiting your daughter in 
outside of Portland when you started experiencing heart irregularities. You say that you went the emergency 
room, and the hospital immediately admitted you to the hospital. You say that the next day the doctor told you 
that you may only have one more day to live. The Plan denied your request. The Plan says that the care was 
received from an out-of-network provider without prior authorization. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health. The rules also 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. 
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. In addition, the Plan has not made reasonable and diligent efforts 
to gather and forward us information needed for our review. The Plan did not provide any medical records or 
evidence of having made reasonable attempts to obtain medical records.  Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided on November 30, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 24, 
2022, through February 26, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.   
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We 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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department with diarrhea, abdominal pain, and 
fatigue for three days and had fallen down several times due to weakness. His vital signs were stable. The 
electrocardiogram showed atrial fibrillation, paced. His white blood cell count was elevated. The computed 
tomography (CT) scan showed evidence of dynamic ileus with possible enteritis. The workup revealed 
Rotavirus. He was started on intravenous fluids, a gastrointestinal cocktail, pain control, antibiotics, and 
glucagon. The enrollees symptoms and labs improved with initial treatment, and he remained  
hemodynamically stable. Due to the quick response to early treatment, stable condition, and insufficient 
evidence of sepsis, it was not expected that the enrollee would require hospital services that would likely cross 
two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. 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 acute inpatient hospital care provided from February 24, 2022, through February 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is medically necessary. 
The Plan denied your request. The Plan says a home ventilator is not medically necessary because the patient's 
needs can be met with a bilevel positive airway pressure (BiPAP) device with average volume-assured pressure 
support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the enrollee is a 79 year old 
male with a history of chronic obstructive pulmonary disease, atrial fibrillation, coronary artery disease, 
diabetes mellitus, sleep apnea, hypertension, and a myocardial infarction. He presented to the hospital on May 
3rd, 2023, with atrial fibrillation with rapid ventricular rate. He was also dyspneic. His arterial blood gases on 
May 4th, 2023, demonstrated hypercapnia. He was treated with nebulizers and antibiotics, in addition to 
treatment for atrial fibrillation. There is a discharge summary from May 17th, 2023, at which time he was 
maintained on supplemental oxygen at 3 liters per minute. The notes indicate he has been on CPAP but the 
machine broke. The submitted order form for a non-invasive ventilator, signed June 9th, 2023, indicates that 
the device is to be used in AVAPS-AE mode, which can be provided by some BiPAP devices.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88112 billed for date of service January 19, 
2023. 
 You asked the Plan to pay for procedure code 88112. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 88112 is bundled into payment for code 88173. 
 
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 88112 
is a column II code to column I code 88173. 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 88112 billed for date of service January 19, 
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 January 20, 
2023.   
You asked the Plan to pay for procedure code A0425. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 1.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 270 units of 
this code, exceeding the MUE. 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 January 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 27, 2022, billed with 
codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81351, 81406, 
81437. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 27, 2022, billed with codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 
81321, 81334, 81351, 81406, 81437.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0675 for date of service August 11, 2022.  
 
You asked the Plan to pay for code E0675. You say that this item was medically necessary and should be 
covered. The Plan denied your request. The Plan says this item is not a covered benefit. The Plan must follow 
Medicare rules. Medicare rules say that claims for PCDs billed with code E0675 will be denied as not 
reasonable and necessary. You billed the PCD in question with code E0675. Therefore, we decided that the 
Plan does not have to pay for the PCD billed with code E0675 for date of service August 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on November 29, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you were visiting your daughter in 
outside of Portland when you started experiencing heart irregularities. You say that you went the emergency 
room, and the hospital immediately admitted you to the hospital. You say that the next day the doctor told you 
that you may only have one more day to live. The Plan denied your request. The Plan says that the care was 
received from an out-of-network provider without prior authorization. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health. The rules also 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. 
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. In addition, the Plan has not made reasonable and diligent efforts 
to gather and forward us information needed for our review. The Plan did not provide any medical records or 
evidence of having made reasonable attempts to obtain medical records. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided on November 29, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease and obstructive sleep apnea. The provided records document that the home ventilator is 
being requested for use in average volume assured pressure support (AVAPS) mode with auto-EPAP (AE) 
which could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a back-up 
rate. The provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up 
rate. The provided records in this case do not provide adequate detailed information to meet Medicare criteria 
for coverage of a ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. Therefore, the 
enrollee does not meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation provided on December 7, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation. 
 
We looked at the file and Medicare rules. The record shows that the claim was billed with primary diagnosis 
code R65.11. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. 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 the ambulance transportation 
provided on December 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 3, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 20 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service February 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 11, 2022 to July 8, 
2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan previously. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the home health services have not been met. Therefore, 
we decided that the Plan does not have to pay for home health services provided on May 11, 2022 to July 8, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 21, 2022. 
 
You asked the Plan to pay for the medical services. You say that the provider reactivated his Medicare 
participation prior to the date of service. The Plan denied your request. The Plan says the provider of the 
services has opted out of Medicare, so this claim cannot be paid. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Although you contend that the provider was not opted-out, the 
document you provided from Medicare does not list the dates of activation for this provider's status. Instead, the letter you provided to support your appeal is just a 'change of information' application with no dates listed. 
Therefore, we decided that the Plan does not have to pay for medical services provided on July 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 4, 2022, to April 
30, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. 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, the start of care date is April 4, 2022. The NOA was not received by the Plan until July 27, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, 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 
April 4, 2022, to April 30, 2022.