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

 
We decided that the Plan does not have to pay for procedure code E0675 billed for dates of service March 21, 
2023, to March 31, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was treated for post-surgical 
lymphedema. The Plan denied your request. The Plan says the code is not eligible for reimbursement. 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 E0675 is not supported in the medical record. A PCD coded E0675 is used in the 
treatment of peripheral arterial disease. Claims for E0675 will be denied as not reasonable and necessary. There 
is a more applicable code that describes a PCD for the treatment of lymphedema. 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 E0675 billed for dates of service March 21, 2023, to March 
31, 2023.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for diagnosis code G93.41 . We decided that the Plan does not have to pay 
for diagnosis code A41.9.  
 
You asked the Plan to pay for inpatient hospital services provided on February 9, 2023, to February 12, 2023, 
at the Diagnosis Related Group (DRG) originally billed. You say that the claim was accurately billed with the 
appropriate DRG. The Plan says that the medical records did not have sufficient documentation to clinically 
validate the diagnoses of A41.9 Sepsis, unspecified organism and G93.41 Metabolic encephalopathy. 
 
We decided that the Plan has to pay for diagnosis code G93.41.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with A41.9 defined as sepsis, unspecified organism and 
G93.41 metabolic encephalopathy. 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 inpatient 
hospital services at the DRG originally billed. Our physician reviewer found there is no evidence of sepsis 
(such as, hypotension, hypoperfusion, organ failure). Therefore, code A41.9 (sepsis) is not supported. 
However, there is evidence of altered mentation beyond the patients baseline dementia. Therefore, code 
G93.41 is supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the claim billed with G93.41. Therefore, we decided that the Plan has to pay for 
diagnosis code G93.41.  
 
We also decided that the Plan does not have to pay for diagnosis code A41.9. 
 
As noted above, our reviewer found that the diagnosis code A41.9 is not supported. Therefore, we decided that 
the Plan does not have to pay for diagnosis code A41.9. 
 
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 an expandable controller for an approved power 
wheelchair (E2313, E2311, E2377). 
 
You asked the Plan to pre-approve the expandable controller. You say that this feature is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when medically 
necessary. 
 
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 expandable controller. Our reviewer 
says that the requested controller is not medically necessary. Our physician reviewer found the record shows 
that the enrollee is capable of operating the power functions using the standard switches. 
 
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 expandable controller have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller for an approved power wheelchair (E2313, E2311, 
E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 3, 2023, by an out-
of-network (OON) provider.  
 
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 the services were rendered by an out-of-network provider without prior authorization. 
 
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 laboratory services provided on July 3, 2023, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on July 27, 2023. 
 
You asked the Plan to pay for the testing billed. You say that the clinical utility of the test has been validated. 
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. The Invitae panel test was billed using codes 81432 and 81433. The Plan has agreed to pay for code 81432. 

We looked at the file and Medicare rules. This NGS panel test was not billed with a single code as required. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to further pay for the panel testing provided on July 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70460 billed for date of service May 14, 
2023. 
 You asked the Plan to pay for procedure code 70460. You say that the service was separate and distinct. The 
Plan denied your request. The Plan says payment for code 70460 is bundled into payment for code 0042T. 
 
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 70460 is a column II code to column I code 0042T. Code 70460 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 70460 
billed for date of service May 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the headgear, coded A7035, billed for date of service June 
26, 2023. 
 
You asked the Plan to pay for the billed item. 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 physician order for the supplies provided in this case. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the headgear, coded A7035, billed for date of service June 26, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiologic examination (x-ray) of the chest (71045) provided on 
March 17, 2023. 
 
You asked the Plan to pay for the x-ray. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says that that code 71045 was billed on two separate claims for the same 
date of service. The Plan says that the first claim received was for an emergency room visit that billed code 
71045, this claim was paid. 
 
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. We find that the Plan hasnt provided any evidence that the services were 
previously billed and paid.  Therefore, we decided that the Plan has to pay for the radiologic examination (x-
ray) of the chest (71045) provided on March 17, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional initial vessel revascularization (37220-59) and 
hospital care (99223-57) provided on June 21, 2023. 
 
You asked the Plan to pay for an additional initial vessel revascularization and hospital care. You say that this 
was billed correctly. The Plan denied your request. The Plan says these services cannot be paid as billed. 
 The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service. The -57 modifier is not used with 
minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. 
Moreover, where the decision to perform the minor procedure is typically done immediately before the service, 
it is considered a routine preoperative service and a visit or consultation is not billed in addition to the 
procedure. 
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the records do not show that the initial vessel revascularization billed with code 37220-59 
were for a different encounter, procedure, site, or injury from the initial vessel revascularization billed with 
37221. The service billed with 99223-57 was performed on the same day as a minor surgery and is not 
separately payable. 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 an additional initial vessel 
revascularization (37220-59) and hospital care (99223-57) provided on June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 13 units 87798 provided March 24, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the billed units 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 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 found the medical records 
provided does not include sufficient documentation to validate billing 13 units of 87798; therefore, this service 
cannot be verified.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for 13 units 87798 provided March 24, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a bladder endoscopy provided on June 9, 
2023. 
 
You asked the Plan to waive the copayment for bladder endoscopy. You say that you do not feel this cost is 
justified. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $275 
copayment for bladder endoscopy in an ambulatory surgical center. This procedure was performed by an 
ambulatory surgical center; therefore, the ambulatory surgical center copayment applies to this claim. 
 
You have been asked to pay $275 copayment for bladder endoscopy. This item/service falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a bladder endoscopy 
provided on June 9, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
You asked the Plan to waive the cost-sharing for fundus photography provided on July 6, 2023. You say that 
you are getting a copayment but do not have coverage for routine eye exams. The Plan says that this cost 
sharing was charged correctly.  We decided that the Plan has to reduce the cost-sharing for eye imaging.  
 
The rules say that a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you pay 20% 
coinsurance for out-of-network eye imaging. The allowed amount of this service is $25, resulting in a 
coinsurance amount of $5. 
 
The Plan says that you must pay the allowed amount of $25 for eye imaging. Based on your contract with the 
Plan, however, you cannot be asked to pay more than $5 which is 20% coinsurance for eye imaging. Therefore, 
we decided that the Plan has to reduce the cost-sharing for eye imaging.  
 
We also decided that the Plan does not have to waive the cost-sharing for eye imaging. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for out-of-network eye imaging. The allowed amount of this service is $25, resulting in a 
coinsurance amount of $5. Therefore, we decided that the Plan does not have to waive the cost-sharing for eye 
imaging. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement, self-care/home management training, 
therapeutic activities, physical therapy, and hospital outpatient clinic visit provided on May 8, 2023, by an out-
of-network (OON) provider.  
 You asked the Plan to pay for the debridement, self-care/home management training, therapeutic activities, 
physical therapy, and hospital outpatient clinic visit. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 debridement, self-care/home management 
training, therapeutic activities, physical therapy, and hospital outpatient clinic visit provided on May 8, 2023, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening mammography, bilateral (2-view study of each 
breast), including computer-aided detection (CAD) when performed (77067) and screening digital breast 
tomosynthesis, bilateral (List separately in addition to code for primary procedure) (77063) provided on June 
30, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the diagnostic services. You say that you have attached medical records for 
review and processing for payment. 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 screening mammography, bilateral (2-view study 
of each breast), including computer-aided detection (CAD) when performed (77067) and screening digital 
breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) (77063) provided on 
June 30, 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 wound care supplies provided on January 10, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that you are requesting reconsideration of 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 the wound care supplies 
provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99203, 83861, and 83516 provided on 
August 22, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure codes 99203, 83861, and 83516. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were 
neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
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 procedure codes 99203, 83861, and 83516 
provided on August 22, 2023, by an out-of-network (OON) provider.