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

We decided that the Plan does not have to pay for closed treatment of proximal humeral (surgical or anatomical 
neck) fracture (23600) closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation (27197) 
provided June 15, 2020. 
 
You asked the Plan to pay for the surgical services. You say that please see attached documentation which 
indicates that 6/15/20 was the correct date of service for this claim. Please reconsider payment. The Plan denied 
your request. The Plan says the records do not support the billed service. 
 
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 find that CPT code 23600 and 27197 is not supported in the medical record. Specifically, for 
23600 the records submitted did not include documentation of closed treatment of proximal humeral (surgical 
or anatomical neck) fracture. For 27197 the records did not include documentation of closed treatment of pelvic 
ring fracture, dislocation, diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without 
anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, 
unilateral or bilateral. The plan had made multiple attempts to obtain the additional information from the 
provider. Based on this information, we decided that Medicare rules for coverage of the surgical services have 
not been met. Therefore, we decided that the Plan does not have to pay for closed treatment of proximal 
humeral (surgical or anatomical neck) fracture (23600) closed treatment of pelvic ring fracture, dislocation, 
diastasis or subluxation (27197) provided June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 4, 2020. 
 
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 procedure codes 41155, 61590, 42894, 64605, 38724, 42420, and 42450 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. 
 
In this case, the CPT Code Manual definition of code 41155 is glossectomy; composite procedure with 
resection floor of mouth, mandibular resection, and radical neck dissection (Commando type). 
 
The definition of code 61590 is infratemporal pre-auricular approach to middle cranial fossa (parapharyngeal 
space, infratemporal and midline skull base, nasopharynx), with or without disarticulation of the mandible, 
including parotidectomy, craniotomy, decompression and/or mobilization of the facial nerve and/or petrous 
carotid artery. 
 
The definition of code 42894 is resection of pharyngeal wall requiring closure with myocutaneous or 
fasciocutaneous flap or free muscle, skin, or fascial flap with microvascular anastomosis. 
 
The definition of code 64605 is destruction by neurolytic agent, trigeminal nerve; second and third division 
branches at foramen ovale.  
 
The definition of code 38724 is cervical lymphadenectomy (modified radical neck dissection). 
 
The definition of code 42420 is excision of parotid tumor or parotid gland; total, with dissection and 
preservation of facial nerve. 
 
The definition of code 42450 is excision of sublingual gland. 
 
We find that CPT codes 41155, 61590, 42894, 64605, 38724, 42420, and 42450 are not supported in the 
medical record. 
 
Specifically, there is no documentation of a glossectomy to support code 41155. The operative report does not 
include an infratemporal pre-auricular approach to middle cranial fossa to support code 61590. The operative 
report does not include documentation of resection of the pharyngeal wall to support code 42894. There is no 
documentation of resection or excision of a neoplastic, vascular, or infectious extradural lesion of the 
infratemporal fossa to support code 61605. There is no documentation of a cervical lymphadenectomy to 
support code 38724. There is no documentation of a total excision of a parotid tumor or parotid gland to 
support code 42420. There is no documentation of an excision of sublingual gland to support code 42450. 
 
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 surgical services rendered on February 4, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA is only covered for certain indications. 
 
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 radiofrequency ablation. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found the enrollee has chronic back pain and had 2 separate radiofrequency ablation 
(RFA) performed within the past 11 months. The degree and duration of the pain relief and effect on activities 
of daily living is not clearly documented. The LCD clearly limits the number of RFA injections to four RFA 
injections per session, limits the radiofrequency ablation sessions to two per rolling 12-month period per region 
irrespective of whether those RFA injections were bilateral or unilateral in that region/ and limits the interval 
between those RFA sessions to 6 months for the same joint. Therefore, the enrollee does not meet criteria for 
the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat 
exchanger services coded 99190 provided on October 28, 2019. 
 
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger services. 
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
services billed are not separately 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 find that CPT code 99190 is not supported in the medical record. Specifically, the enrollee received these 
services during an inpatient hospital stay. Therefore, this service is included in the part A DRG payment to the 
facility. Based on this information, we decided that Medicare rules for coverage of the assembly and operation 
of pump with oxygenator or heat exchanger services have not been met. Therefore, we decided that the Plan 
does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 
99190 provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for group therapeutic procedures (97150) and electrical 
stimulation (97014) provided on January 22, 2020. 
 
You asked the Plan to pay for group therapeutic procedures and electrical stimulation. You say that these codes 
are documented in the records. The Plan denied your request. The Plan says these 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. The rules also say that status code "I = Not valid 
for Medicare purposes. Medicare uses another code for reporting of, and payment for these services." 
 
In this case, the CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more 
individuals). CPT Code 97014 has a status code of I. 
 
We find that CPT codes 97150 and 97014 are not supported in the medical record. Specifically, the records do 
not contain documentation of a group procedure as indicated by 97150. 97014 has a status indicator of "I." 
Medicare uses another code for reporting of, and payment for these services. Based on this information, we 
decided that Medicare rules for coverage of group therapeutic procedures and electrical stimulation have not 
been met. Therefore, we decided that the Plan does not have to pay for group therapeutic procedures (97150) 
and electrical stimulation (97014) provided on January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection rendered on April 23, 2020. 
 
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 screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, infectious agent detection, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the infectious agent detection rendered on April 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on January 10, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records provided do not support the services billed. Lab results were not submitted 
for the date of service in question. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and provide documentation to support the 
services billed. In this case, the records provided do not support the lab services billed. Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided to the enrollee on January 10, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided on June 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this provider is not 
eligible to be paid for these services. 
 
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 codes in question are payable codes for physician services. There is no 
evidence that the provider does not meet the definition of an NP and she has a valid NPI number. No evidence 
is provided to show that the services were provided outside the scope of the NP's State license. The Plan has 
not provided any evidence to support that this provider cannot be paid for the services at issue. Therefore, we 
decided that the Plan has to pay for the services provided on June 10, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided 
from December 30, 2019, to January 4, 2020. 
 
You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you feel that the 
inpatient hospital stay should not be billed separately from a previous stay. The Plan denied your request. The 
Plan says the claims were processed correctly and you are being charged the correct amount. 
 
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 a $315 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from December 30, 2019, to January 4, 2019. This is considered a new 
inpatient hospital admission. Therefore, you are responsible to pay a $315 copayment for days 1-5 (December 
30, 2019, to January 3, 2020). $315 (copayment) x 5 (inpatient days) = $1,575.  
 
You have been asked to pay the total copayment amount of $1,575 for an inpatient rehabilitation stay. An 
inpatient rehabilitation stay falls within the inpatient hospital care 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 an inpatient rehabilitation stay provided from December 30, 2019, to January 4, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intermittent limb compression device (E0652, E0667). 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that this is necessary to 
reduce the risk of serious complications. The Plan denied your request. The Plan says this is not covered 
without a trial of another device. 
 
The Plan follows Medicare rules. The rules state that a four-week trial of conservative therapy demonstrating 
failed response to treatment with an E0650 or E0651 is required before a device coded as E0652 is 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 intermittent limb compression device. 
Our reviewer says that the criteria for coverage of the requested device have not been met. Our physician 
reviewer found the documentation does not reveal that the patient has unique characteristics that prevent them 
from receiving satisfactory pneumatic compression treatment using a non-segmented device in conjunction 
with a segmented appliance or a segmented compression device without manual control of pressure in each 
chamber. There is no evidence of a failure of the E0651 or E0650 device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve intermittent limb compression device (E0652, E0667).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 7, 2020, to 
February 15, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital services were 
medically necessary. The Plan denied your request. The Plan says that the enrollee only met observation level 
of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was admitted to the hospital. The enrollee was seen by the surgeon who 
recommended a nonsurgical approach due to the fracture being nondisplaced. Although the day after 
admission, the orthopedic surgeon decided to treat the enrollee nonsurgically, at the time of admission, the 
treating physician was considering that the enrollee was likely to require surgery which would have required a 
hospital stay that would cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 7, 2020, to February 15, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that the enrollee 
accidentally threw her previous dentures away. You also say that the enrollee cannot afford to pay for new 
dentures. The Plan denied your request. The Plan says these services exceed the maximum count allowed per 
period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, complete maxillary denture (D5110) 
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record 
shows that the enrollee received a complete maxillary denture (D5110) on March 22, 2018, and a complete 
mandibular denture (D5120) on October 4, 2017, and the enrollee's complete maxillary denture (D5110) and 
complete mandibular denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does 
not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
18, 2020 to May 21, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim 
form submitted does not have the appropriate home health data for the plan to process and pay the claim. The 
provider billed type 323, which is not appropriate for home health services. Therefore, we decided that the Plan 
does not have to pay for the home health services provided to the enrollee from May 18, 2020 to May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120) and prophylaxis (D1110) 
provided on July 30, 2020. 
 
You asked the Plan to pay for the dental services. You say that you had a tooth break off at the gum line. You 
say that your dentist replaced it with a single tooth prosthesis. You say that this was done so that you could 
chew and avoid a digestion problem. The Plan denied your request. The Plan says there is an annual maximum 
benefit of $1,00. The Plan also says that the annual maximum has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the annual maximum benefit of $1,000 
has been exhausted.  
Date of Service      Plan Paid      Your Responsibility 
1/3/2020               $155              $0 
1/16/2020             $254              $0 
1/22/2020             $254              $0 
2/11/2020             $277.50          $50.50 
2/18/2020             $59.50           $59.50 
TOTAL:                $1,000            $110 
 
The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges 
are your responsibility. Therefore, we decided that the Plan does not have to pay for the oral evaluation 
(D0120) and prophylaxis (D1110) provided on July 30, 2020.