Persius/hicric huggingface dataset:
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 August 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. 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 August 
9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (46999) provided on August 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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. 
 
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 use of code 46999 is 
not supported by the records provided. Our reviewer found that the medical records do not support the use of 
procedure 46999 as all procedures done on this date of service can be encompassed in code 46230. 
 
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 the services (46999) provided on August 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36561 billed for date of service May 18, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the surgical assistant had not choice to not be on 
the case. The Plan denied your request. The Plan says the code is not payable. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity.  
 
We looked at the file, and Medicare rules. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 36561. The Medicare Fee Schedule Database contains a surgical indicator 
of 0 for this procedure. The records provided do not show why an assistant was necessary for the minor 
procedure provided. Also, the claim was not billed with modifier -80 or -81 as required. 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 36561 billed for date of service May 18, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stationary compressed gaseous oxygen system, rental; 
includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing (E0424). 
 
You asked the Plan to pre-approve a stationary compressed gaseous oxygen system. You say that the enrollee 
needs this back up system in her house due to power outages and a blood gas analysis. The Plan denied your 
request. The Plan says the clinical documentation received establishes that the stationary tank of oxygen 
requested by the enrollee's physician is for preventive or precautionary purposes. This is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a portable oxygen system is covered if the 
beneficiary is mobile within the home for Groups I and II, and the qualifying blood gas study was performed 
while at rest (awake) or during exercise. 
, 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a stationary compressed gaseous oxygen system have not been met. Specifically, the Plan does not 
cover a portable oxygen system for preventative or precautionary purposes. Therefore, we decided that the Plan 
does not have to pre-approve a stationary compressed gaseous oxygen system, rental; includes container, 
contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing (E0424).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74240, 74230, 92611, 72040, 70100, 70310, 
and 71045 for date of service November 28, 2022. 
 
You asked the Plan to pay for procedure codes 74240, 74230, 92611, 72040, 70100, 70310, and 71045. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 74240, 74230, 92611, 72040, 70100, 70310, and 71045 are not supported in the 
medical record. Specifically, the documentation supports the studies represented by codes 74240, 74230, and 
92611 were performed at a nursing home, which is an excluded place of service for these services. Therefore, 
codes 74240, 74230, and 92611 are not eligible for reimbursement. 
 
Codes 72040, 70100, 70310, and 71045 were billed with place of service 11 (office) however, the 
documentation received does not support the services performed in an office or other outpatient setting. The 
documentation shows the services were provided in the skilled nursing facility place of service. Therefore, the 
place of service billed is not supported for codes 72040, 70100, 70310, and 71045. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 74240, 74230, 
92611, 72040, 70100, 70310, and 71045 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 74240, 74230, 92611, 72040, 70100, 70310, and 71045 for date of service 
November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99496) provided on October 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
payable. 
 
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 use of code 99496 is 
not supported by the records provided. Our reviewer found that the record shows that the same provider 
reported code 99496 on October 11, 2022, and October 27, 2022. The guidelines for code 99496 say it can be 
reported by an individual once per patient withing 30 days of discharge, and another transitional care 
management service cannot be reported by the same individual or group for any subsequent discharged within 
30 days.  
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 the services (99496) provided on October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on May 18, 
2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on May 18, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on October 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed services 
are not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the billed services are not supported and indicates that 
medical records were received from the provider on February 17, 2023. However, the Plan has not provided the 
medical records with the case file. Without supporting documentation, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the services provided on October 21, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response Report and the Cardio 
Hereditary Genetics Panel provided on December 9, 2022, and billed with codes 81225, 81226, 81227, 81231, 
81232, 81240, 81241, 81291, 81306, 81328, 81335, and 81238. 
 
You asked the Plan to pay for the GeneDose Genetic Response Report and the Cardio Hereditary Genetics 
Panel . You say that this testing was medically necessary. The Plan denied your request. The Plan says this 
testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components.  
We looked at the file and Medicare rules. These tests were not billed with single panel codes as required. Based 
on this information, we decided that Medicare rules for coverage of the GeneDose Genetic Response Report 
and the Cardio Hereditary Genetics Panel have not been met. Therefore, we decided that the Plan does not have 
to pay for the GeneDose Genetic Response Report and the Cardio Hereditary Genetics Panel provided on 
December 9, 2022, and billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 
81328, 81335, and 81238.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 1, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 an office visit provided on February 1, 2023, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4253 and A4259 billed for date of service 
July 10, 2021, to October 9, 2021.  
 
You asked the Plan to pay for procedure code A4253 and A4259. You say that you disagree with the Plan's 
denial. 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 A4253 is 1. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. The MUE for CPT code A4259 is 1. The MAI value for this code is 3. You billed 4 
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 A4253 and A4259 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A4253 and A4259 billed for date of service July 10, 2021, to October 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93976 billed for date of service September 
26, 2022. 
 You asked the Plan to pay for procedure code 93976. You say that this is not a bundled charge. The Plan 
denied your request. The Plan says payment for code 93976 is bundled into payment for code 76857. 
 
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 93976 
is a column II code to column I code 76857. 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 93976 billed for date of service September 26, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) provided on July 21, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for drug testing. You say that the services at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for OON services have not been met. 
 
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 drug testing (G0483) provided on July 21, 2022, 
by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 16, 2022, to 
February 14, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the required NOA, but 
the claim has been denied numerous times. 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 January 16, 2022. The NOA was not received by the Plan until March 10, 
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 January 16, 2022, to February 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on October 4, 2022, billed with 
code 78999-ME. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 78999-ME is Unlisted miscellaneous procedure, 
diagnostic nuclear medicine. 
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the medical records do not support the use of procedure 78999 as there is a more appropriate code that can be used for the scan preformed. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on October 4, 2022, billed with code 78999-ME.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that the treatment sought was medically necessary. The 
Plan denied your request. The Plan says the rules for payment have not been met. 
 
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 Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. The panel testing was also not billed with a single 
code as required. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on 
December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on April 28, 
2022, to May 18, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. The Plan denied your request. The Plan says 
this is not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on April 28, 2022, to May 18, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that it is not safe for discharge to home due to the risk of 
injury/falling. The Plan denied your request. The Plan says no skilled nursing needs are identified. Services 
needed may be provided safely in a lower level of care, home health services and 24-hour family supervision. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tendon sheath incision (eg, for trigger finger) rendered on 
September 27, 2022. 
 
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 this is part of the primary procedure and ineligible for separate payment. 
 
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 26055 is "Tendon sheath incision (eg, for trigger finger)." 
 
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 details cite the 
thickened first annular pulley was incised, longitudinally, in the volar midline. This was performed to also 
allow for the excision of the ganglion and would not be a distinctly separate procedure. Therefore, records do 
not support CPT 26055 as a separate and distinct procedure from CPT 26160 in this case. 
 
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 tendon sheath incision (eg, for trigger finger) rendered on September 27, 2022.