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

 
We decided that the Plan does not have to pay for procedure codes 22633, 22634, and 20937 billed for date of 
service August 5, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
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 22633 is arthrodesis, combined posterior or posterolateral 
technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare 
interspace (other than for decompression), single interspace, lumbar. CPT code 22634 is for each additional 
interspace (List separately in addition to code for primary procedure). We find that CPT code 22633 and 22634 
are not supported in the medical records. These codes are used to describe services other than for 
decompression. There are more comprehensive codes to describe the services provided.  
 
The definition of code 20937 is autograft for spine surgery only (includes harvesting the graft); morselized 
(through separate skin or fascial incision) (List separately in addition to code for primary procedure). We find 
that code 20937 is not supported in the medical record. The records do not include autograft services, including 
harvesting of the graft. 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 codes 
22633, 22634, and 20937 billed for date of service August 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve calf rest pads (E0955) and adjustable foot plates 
(K0108). 
 
You asked the Plan to pre-approve calf rest pads and adjustable foot plates. You say that these items are 
medically necessary. The Plan denied your request. The Plan says these items cannot be separately approved. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The rules also say that calf rest pads (E0955) are included in the allowance for a 
power wheelchair base when provided at the same time. 
 
The file shows that the Plan has approved adjustable footplates under code K0040, meaning the footplates 
requested with K0108 are considered a duplicate and are not reasonable and necessary. The requested calf rest pads (E0955) are included in the power wheelchair base and cannot be approved as a separate item. Therefore, 
we decided that the Plan does not have to pre-approve calf rest pads (E0955) and adjustable foot plates 
(K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (88305) provided on July 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that surgical pathology, including gross and 
microscopic examination, of any and all submitted prostate needle biopsy specimens from a single patient be 
reported with one unit of service of HCPCS code G0416 rather than CPT code 88305. 
 
We looked at the file and Medicare rules. The lab services in question were billed with code 88305. Per 
Medicare rules, these services should be billed with code G0416 for coverage to be considered. 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 (88305) provided on July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 25, 2022, to 
September 7, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you believe the admission was 
medically necessary, and you are requesting full reimbursement for this case. The Plan denied your request. 
The Plan says that it has been determined that there is no evidence that acute care was provided, and the 
enrollee's pain was controlled and the emergency department (ED). The Plan also says the enrollee could have 
been managed at the outpatient level of care after evaluation in the ED. 
 
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 the 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 record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) 
would span two 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 the acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from August 25, 2022, to September 7, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the care they need in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gerontology provided on July 31, 2022. 
 
You asked the Plan to pay for gerontology. You say that you are requesting reconsideration. 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 gerontology provided on 
July 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removable prosthodontic procedure (D5899). 
 
You asked the Plan to pre-approve a removable prosthodontic procedure. You say that you would like to appeal 
this service. The Plan denied your request. The Plan says this service is not covered under your benefit 
package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
removable prosthodontic procedure (D5899).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 90792. We decided that the Plan does not have to pay 
for procedure codes 80307 and 82075.  
 
You asked the Plan to pay for procedure codes 80307, 82075 and 90792 billed for dates of service from 
September 6, 2022, to September 7, 2022.. You say that the services at issue have been billed correctly. The 
Plan says that rules for payment have not been met. 
 
We decided that the Plan has to pay for procedure code 90792.  
 
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. Specifically, the Plans denial states that procedure code 90792 has an OPPS 
status indicator of Q4. We found no support for this assertion. Procedure code 90792 has an OPPS status 
indicator of Q3. It is the Plans responsibility to substantiate its denial with evidence. In this case, the Plans 
denial has not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay 
for procedure code 90792.  
 
We also decided that the Plan does not have to pay for procedure codes 80307 and 82075. 
 
The Plan follows Medicare rules. Medicare rules say that status indicator Q4 designates packaged APC 
payment if billed on the same claim as a HCPCS code assigned status indicator J1, J2, S, T, V, 
Q1, Q2, or Q3. 
 
In this case, procedure codes 80307 and 82075 have a status indicator of Q4 and have been billed alongside 
code 99284, which has a status indicator of J2, and codes 90791 and 90792, which have a status indicator of 
Q3. Procedure codes 80307 and 82075 are therefore designated packaged APC payment. Therefore, we decided 
that the Plan does not have to pay for procedure codes 80307 and 82075. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
19, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like this claim reprocessed and 
approved for payment. 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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee does not have the proper 
things to be taken care of long term and that they need care that is close to home as the representative is their 
sole caregiver. It is also stated that the enrollee is at risk for developing an infection in their knee which 
increases the risk of readmission to the hospital. The Plan denied your request. The Plan says the request is not 
medically necessary, when the enrollee is ready to leave the hospital, they can safely receive this care in 
another setting, such as a Skilled Nursing Facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service February 5, 2021, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. The Plan denied your request. The Plan says code 99153 
is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service February 5, 2021, billed 
with code 99153.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keppra. 
 
You asked the Plan to pre-approve Keppra. You say that this medication is medically necessary for the enrollee 
to take for the rest of their life, and you would highly advise against changing or stopping it. The Plan denied 
your request. The Plan says Keppra is a self-administered drug, and is not covered for the enrollee's condition 
by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Keppra.  
 
Benefits for Keppra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary, when the enrollee 
is ready to leave the hospital, they can safely receive this care in another setting, such as a Skilled Nursing 
Facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on March 22, 2022. You asked the Plan to pay for the panel testing. The Plan denied your request. The Plan says one code must be 
submitted for the panel. 
 
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 file shows that the general gene panel at issue was billed with multiple codes, including code 81335. We 
find that the panel testing was not billed with a single code as required. Based on this information, we decided 
that Medicare rules for coverage of the panel testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the gene panel testing provided on March 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound (76642) provided on August 24, 2022. 
 
You asked the Plan to pay for the breast ultrasound. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the breast ultrasound have not been met. CPT code 76642 exceeds 
the allowable UOS of 1 for the same date of service per the MAI indicator of 2 and was not billed correctly; 
we find that Medicare rule for payment of this claim has not been met. If the provider determines that a billing 
error occurred during the initial submission of the denied claim, the Plan will accept a submission of a 
corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for 
the breast ultrasound (76642) provided on August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) month rental to cap purchase of a group 2 
standard captains chair power wheelchair (E2365NU) and purchase two (2) power wheelchair batteries 
(K0823RR). 
 
You asked the Plan to pre-approve the DME. You say that the enrollee complains of increasing difficulty 
getting around on their own and is partially blind. The Plan denied your request. The Plan says the home is not 
safe/suitable for either a power operated vehicle (POV)/Scooter or power wheelchair. The Plan states a rolling 
walker with a seat may meet the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer 
found the documentation indicates the enrollee is not able to use a power mobility device safely in the home 
due to insufficient space.  
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ten (10) month rental to cap purchase of a group 2 standard captains chair power wheelchair 
(E2365NU) and purchase two (2) power wheelchair batteries (K0823RR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (CPT 
code A4595) provided on June 10, 2022. 
 
You asked the Plan to pay for the items. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the items have not been met. The Proof of Delivery did not include 
an order number or details to corroborate the Delivery Ticket submitted. Of note, the Proof of Delivery is not 
itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified. Unable to verify 
referring provider or any type of established relationship. Therefore, we decided that the Plan does not have to 
pay for the electrical stimulator supplies, 2 lead, per month (CPT code A4595) provided on June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93320 and 93325 billed for date of service 
March 16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were rendered in good faith. The 
Plan denied your request. The Plan says the billed services cannot be verified. 
 
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 93320 is doppler echocardiography, pulsed wave and/or 
continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); 
complete. The CPT Code Manual definition of code 93325 is doppler echocardiography color flow velocity 
mapping (List separately in addition to codes for echocardiography). 
 
We find that CPT codes 93320 and 93325 are not supported in the medical record provided. 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 pay for procedure codes 93320 and 93325 billed for date of service March 16, 2022.