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

 
We decided that the Plan has to pay for laboratory testing services (88184, 88185) billed for date of service 
May 18, 2023. 
 
You asked the Plan to pay for laboratory testing services. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says that 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. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the Plan has not provided evidence of the 
prior claim. Based on this information, we decided that Medicare rules for coverage of laboratory testing 
services have been met. Therefore, we decided that the Plan has to pay for laboratory testing services (88184, 
88185) billed for date of service May 18, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service February 1, 
2023. 
 You asked the Plan to pay for procedure code 81345. You say that you request for overturn of the denial and 
reprocessing of the claim according to CMS guidelines. The Plan denied your request. The Plan says payment 
for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service February 1, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the IDgenetix test (81479) provided on April 4, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that your claim for the IDgenetix test was denied in 
error and you are requesting it be reprocessed and paid The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 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 items/services 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 these items/services. 
Therefore, we decided that the Plan does not have to pay for the IDgenetix test (81479) provided on April 4, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
rendered on June 8, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 continuous positive airway pressure (CPAP) device 
rendered on June 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel provided March 14, 2023, billed with 
codes 87481, 87500, 87640, 87652, 87798 x13, 87798-91 x8. 
 
You asked the Plan to pay for the laboratory testing. You say that this test was ordered based upon the treating 
physician's clinical training and medical necessity. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. The unbundling of lab codes for PCR panel testing is not appropriate. The standard of care for the 
evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. Based on this information, we 
decided that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the Urine PCR panel provided March 14, 2023, billed with codes 87481, 
87500, 87640, 87652, 87798 x13, 87798-91 x8.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 18, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 provided 
on July 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82306, 82728, 83036, 83540, 83550, 84466, 
84480) provided on July 10, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have billed the services at issue correctly. 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 lab services (82306, 82728, 83036, 83540, 83550, 84466, 84480) provided on 
July 10, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837) provided on May 30, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services should be covered. The Plan denied 
your request. The Plan says services are not covered for this type of provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90837) provided on 
May 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on July 5, 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 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 F32.1 has an Excludes1 note in relation to F31.0. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
drug testing rendered on July 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the Medicare criteria 
for inpatient LTAC that cannot be accomplished at a lower level of care.  The Plan denied your request. The 
Plan says the LTACH services are not medically necessary, and the enrollee's needs are being met in the 
current hospital location.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with subdural hematoma and 
acute respiratory failure following a fall requiring bur hole evacuation, embolization artery hemorrhage, intubation, and blood transfusion and complicated by bacteremia requiring antibiotics. The enrollee appears to 
be improving with current treatment and should only require short-term additional acute care services that can 
safely be provided at the current facility until more stable and appropriate for transfer to a lower level of care 
soon. The enrollee does not require services at the LTACH that are not already available at the current facility.   
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on June 5, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services 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 M50.30 has an Excludes1 note in relation to M54.2. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the medical services have not been met. Therefore, we decided that the Plan does not have to 
pay for medical services provided on June 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device 
(E0601) provided from March 5, 2023, to April 4, 2023. 
 
You asked the Plan to pay for a CPAP device. You say that you have billed the item at issue correctly. The 
Plan denied your request. The Plan says the item at issue should be billed with 1 unit per rental month. 
 
The Plan must follow Medicare rules. Medicare rules say that for oxygen and oxygen equipment, Medicare 
pays a monthly fee schedule amount per beneficiary. Fee schedule payments for stationary oxygen system 
rentals are all inclusive and represent a monthly allowance per beneficiary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device have not been met. Specifically, the item at issue has been inappropriately billed with 31 units for the rental month. Therefore, we decided that the Plan does not have to pay for a continuous 
positive airway pressure (CPAP) device (E0601) provided from March 5, 2023, to April 4, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99284 
for June 10, 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 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 on August 18, 2023. 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 these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99284 for 
June 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on March 28, 2023. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the supplies provided on March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standing frame/table system (E0642) and sales tax 
(S9999) purchased on May 10, 2023. 
 
You asked the Plan to pay for the standing table and sales tax. You say that the items should be covered. The 
Plan denied your request. The Plan says these are noncovered items. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the standing frame/table system (E0642) and sales tax (S9999) 
purchased on May 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collection of venous blood by venipuncture (36415) Per Mile 
Travel Allowance (P9603) provided February 24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the absence of immediate insurance 
information at the time of service delivery was due to the enrollee's inability to provide these details during 
their visit. The Plan denied your request. The Plan says the claim was submitted after the timely filing 
limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until July 14, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for collection of venous blood by venipuncture (36415) Per Mile 
Travel Allowance (P9603) provided February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker (E0143) purchased on July 15, 2023. 
 
You asked the Plan to pay for the walker. You say that the item was medically necessary. The Plan denied your 
request. The Plan says this item was purchased through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the walker (E0143) purchased on July 
15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675), provided on 
March 23, 2023, through April 10, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675), provided on March 23, 2023, through April 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTAC is medically necessary.  The 
Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs are 
being met in the current hospital location. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) on home oxygen 
who was admitted to the acute care hospital with acute on chronic respiratory failure, congestive heart failure, 
severe pulmonary hypertension requiring bi-level positive airway pressure (BiPAP), oxygen support, steroids, diuresis. The enrollee appears to be improving with current treatment and should only require short-term 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care soon. The enrollee does not require services at the LTACH that 
are not already available at the current facility.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87798, 87481, 87653, 87563, 87640, 
87651, 87551, 87556, 87561, 87500, 87641, and 87801) provided on February 1, 2023. 
 
You asked the Plan to pay for procedure codes 87798, 87481, 87653, 87563, 87640, 87651, 87551, 87556, 
87561, 87500, 87641, and 87801. You say that you would like the Plan to reconsider their denial of payment. 
The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87798, 87481, 87653, 87563, 87640, 87651, 87551, 87556, 87561, 87500, 87641, and 
87801 are not supported in the medical record. Specifically, a panel was performed and there is a more 
appropriate singular code for the services. 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 
panel testing (87798, 87481, 87653, 87563, 87640, 87651, 87551, 87556, 87561, 87500, 87641, and 87801) 
provided on February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99239 billed for date of service May 14, 2023. 
 
You asked the Plan to pay for code 99239. You say that this code was billed correctly. The Plan denied your 
request. The Plan says the code at issue is 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 99239 is Hospital discharge day management: more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the code definition is time-
based, and the records submitted for review do not document the total time spent providing the services 
described by this code. Based on this information, we decided that Medicare rules for coverage of code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for code 99239 billed for date of 
service May 14, 2023.