Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0130). 
 
You asked the Plan to pre-approve additional transportation trips. You say that additional trips are needed to 
get the enrollee to his appointments. The Plan denied your request. The Plan says the enrollee has exhausted 
the maximum benefit of 48 one-way trips per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0130).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the recoupment request for practitioner services provided on 
October 8, 2020, billed with procedure code 32100. 
 
You asked the Plan to waive the recoupment request for the practitioner services provided. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says code 32100 is billed 
with code 22556 and is supposed to be paid at 50% the fee schedule amount. 
 
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 the services described by code 32100 is Thoracotomy; with 
exploration. 
 
  
We find that the Plans request for recoupment of 50% of the amount paid for 32100 is supported. Specifically, 
both codes 32100 and 22556 have a multiple procedure indicator of 2 which means that standard payment 
adjustment rules for multiple procedures apply. As such, the highest paid code (22556) is paid at 100% while 
the subsequent codes are paid at 50% of the fee schedule amount. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to waive the recoupment request for practitioner services provided on October 8, 2020, 
billed with procedure code 32100.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307, G0480 and 83789 billed for date of 
service February 10, 2023. 
 
You asked the Plan to pay for procedure codes 80307, G0480 and 83789. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the provided records do not support the 
services 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. The rules also say that providers performing 
validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. 
 
We find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, the record 
indicates that a custom panel of tests was ordered. However, the order does not identify the tests that 
constituted the panel. 
 
We also decided that Medicare rules for coverage of procedure code 83789 have not been met. Specifically, we 
find that the testing described by the billed code is considered specimen validity testing which is not separately 
payable. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 80307, G0480 and 
83789 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 80307, 
G0480 and 83789 billed for date of service February 10, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95938, 95861, 95937, and 95940 billed for 
date of service March 9, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services are separate from the facility. The 
Plan denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim at issue was billed with 15, a mobile unit place of service code. 
The place of service code should reflect the actual place where the enrollee receives the face-to-face service 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 95938, 95861, 95937, and 
95940 billed for date of service March 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87150, 87500, 87641, 87653, 87798, 
87801 and 87481) provided December 15, 2022.  
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not submit detailed progress notes that are needed in order to 
determine the clinical utility of the services performed. 
 
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 laboratory services have been met. 
Progress notes are needed in order to determine the clinical utility of the services performed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (87150, 87500, 87641, 87653, 87798, 
87801 and 87481) provided December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic and outpatient rehabilitation services 
provided from January 30, 2023, to February 3, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed codes 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 procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. 
 
We find that procedure code G0283 was billed with the GP modifier. Outpatient non-rehabilitation HCPCS 
codes G0237, G0238, and G0239 should be billed without therapy modifiers. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. 
 
We find that procedure codes 97012 and 97110 were billed with the GP modifier. The records provided do not 
include a plan of care as required to support the services. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. 
 
We find that codes 98941 and 98943 are not supported. The records provided do not describe the specific 
manipulative adjustments provided. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the 
chiropractic and outpatient rehabilitation services provided from January 30, 2023, to February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service May 9, 2023.  
 
You asked the Plan to pay for procedure code 86077. You say that the records support the frequency billed. 
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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service May 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on January 7, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that this claim should be paid. 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 March 11, 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 the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on January 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 9, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on February 9, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 30, 2022, to 
February 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was 
submitted. 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 January 30, 2022, to 
February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 14, 2023, billed with 
procedure codes A6197-A2 and A6196-A2. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the documentation does not include proof of 
delivery. 
 
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 codes A6197-A2 and A6396-A2 is alginate or other fiber 
gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each 
dressing, and alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less, each 
dressing.  
We find that CPT codes A6197-A2 and A6396-A2 is not supported in the medical record. Specifically, no 
proof of delivery has been provided for the date of service in question to support the billed codes. Based on this 
information, we decided that Medicare rules for coverage of the practitioner services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on April 14, 
2023, billed with procedure codes A6197-A2 and A6196-A2.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient psychiatric hospital admission.  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says an acute inpatient psychiatric hospital admission is not 
medically necessary.  
  
 
 
 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 this service. Our reviewer says that an 
acute inpatient psychiatric hospital admission is not medically necessary. Our physician reviewer found that the 
progress notes do not indicate that the enrollee had been aggressive with peers or staff on the unit or had any 
recent attempt to harm herself as of the last covered date. There was no indication in the available medical 
records that the enrollees psychiatric symptoms could not be managed in the previous psychiatric facility or on 
a less restrictive basis. She was noted to have confusion and ongoing psychosis at her baseline mental status.  
The enrollee was not exhibiting any other significant symptoms that would require a transfer into the current 
hospital. She had no acute psychiatric issues that would require continued inpatient care. The enrollee has 
chronic symptoms. The available medical records do not support that inpatient care would have changed these 
symptoms or the enrollees current condition. The enrollee is chronically impaired due to her psychiatric 
condition and a continued inpatient hospital stay was not expected to improve the enrollees condition in a 
reasonable period of time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an acute inpatient psychiatric hospital admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on April 10, 2023. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. 
 
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 pay for the urine PCR panel testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the standard of care for the evaluation of urinary incontinence is urinalysis with 
urine culture and sensitivity. The PCR testing is considered unproven and not medically necessary. The review 
has determined that the items/services at issue in this case are not medically reasonable or necessary. 
 
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 urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on April 10, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00812 rendered on March 4, 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 Current Procedural Terminology (CPT) code 00812 AA (28 units) remains 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 00812 is "Anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; screening colonoscopy." 
 
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 procedure report documents a 
diagnostic colonoscopy.  In this case, a procedure for screening is not supported. There is a more appropriate code to report for service provided. 
 
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 procedure code 00812 rendered on March 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the brace (A4467). 
 
You asked the Plan to pay for the brace. You say that the item should be covered. The Plan denied your 
request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that Code A4467 is denied as noncovered (no 
Medicare benefit).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the brace have not been met. Therefore, we decided that the Plan does not have to pay for the brace 
(A4467).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 20, 2023, to 
February 18, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was 
submitted. 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 January 20, 2023, to 
February 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260x12). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that your body is falling apart. You 
have arthritis in both legs and two bad knees. The requested bed is medically necessary. The Plan denied your 
request. The Plan says you do not meet criteria for the requested bed. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
states your condition requires positioning of the body in ways not feasible in an ordinary bed. The 
documentation does not support that you require frequent or immediate changes in body position. The 
documentation does not support that your condition requires special attachments that cannot be fixed and used 
on an ordinary bed. The semi-electric hospital bed is not medically necessary for you. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260x12).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 20, 2022, to 
January 26, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says no clinical information supporting medical necessity was submitted. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We looked at the file and Medicare rules. Review of the file shows that no clinical information (medical 
records) was submitted to support medical necessity of the services rendered. Based on this information, we 
decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from January 20, 2022, to January 26, 
2022.