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

 
We decided that the Plan does not have to pay for lab services provided on June 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 23, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from December 27, 
2021, to December 30, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the information received does not support an inpatient stay. 
 
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 that the review indicates that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. The electrocardiogram revealed atrial flutter with right bundle 
branch block (RBBB). The enrollee was unable to ambulate. 
 
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 inpatient hospital services provided to the enrollee from December 27, 2021, to December 30, 
2021.  
 
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: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 31, 2021, to 
November 3, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says that the services were not medically necessary. 
 
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 presented to the emergency department (ED) with abdominal and rectal pain, 
nausea, and vomiting. A computed tomography (CT) scan showed several diverticula scattered in the colon. 
The records support 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from October 31, 2021, to November 3, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services (procedure codes 95822, 95999, G0453) 
provided to the enrollee on April 21, 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 the records do not support the services billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 95822: 
 
Electroencephalogram (EEG); recording in coma or sleep only 
 
CPT 95999: 
 
Unlisted neurological or neuromuscular diagnostic procedure 
 
Healthcare Common Procedure Coding System (HCPCS) G0453: 
 
Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), 
per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary 
procedure) 
 
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 that the records do not 
support the use of either CPT 95822 or CPT 95999. Our reviewer found that the he technical report does 
indicate that an EEG was performed. However, this code is not supported as the enrollee was not in a coma or 
sleep. There are more appropriate codes to use in this clinical scenario. (e.g., 95812 and 95813). Therefore, the 
records do not support that CPT 95822: Electroencephalogram (EEG); recording in coma or sleep only were 
rendered. Additionally, the technical report noted that a train of four was utilized to assess the presence of 
neuromuscular blockade. The CPT code 95999 was billed for this procedure. However, train-of-four 
monitoring is considered integral to intraoperative neuromonitoring and/or administration of anesthesia and, 
therefore, is not separately reportable. Therefore, the records do not support that CPT 95999: unlisted 
neurological or neuromuscular diagnostic procedure was rendered. 
 
Additionally, in this case, we have confirmed that code G0453 is a column II code to column I code 51785. 
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. 
 
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 neurology services (procedure codes 95822, 95999, G0453) provided to the enrollee on April 
21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional 4oz tubes of lubricate per month (A4402). 
 
You asked the Plan to pre-approve the service. You say that you are requesting additional (13) 4oz tubes of 
lubricate per month, because the enrollee cannot be catheterized without lubricant. The Plan denied your 
request. The Plan says the enrollee's current supply/prescription of the lubrication gel should be sufficient to 
meet the enrollee's medical needs. The Plan states there is no medical indication for additional lubricant, 2-4oz 
tubes of lubricant per month is adequate to meet the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the additional lubrication gel is not medically necessary. Based on 
review, the enrollee's current supply/prescription of the lubrication gel should be sufficient to meet the 
enrollee's medical needs. The review has determined that the items/services at issue in this case are not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional 4oz tubes of lubricate per month (A4402).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the eye exam with photos (92250) provided on August 30, 2022. 
 
You asked the Plan to pay for the eye exam with photos. You say that you were not aware that the doctor is an 
optometrist. You also say that you have been going to this doctor for an eye exam, and it was paid. The Plan 
denied your request. The Plan says that this service is not covered by the Plan. 
 
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 Plan denied this eye exam with photos saying it is not a covered 
service. We find that this service is a Medicare-covered outpatient diagnostic test, and the Plan has not 
supported their denial of payment in this case. Therefore, we decided that the Plan has to pay for the eye exam 
with photos (92250) provided on August 30, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for angiography, visceral, selective or supraselective (with or without flush 
aortogram), radiological supervision and interpretation provided to the enrollee on July 2, 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 that the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 75726 is "Angiography, visceral, selective or supraselective (with or without flush aortogram), 
radiological supervision and interpretation." 
 
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 supported by the medical records. Our reviewer found that diagnostic angiography in preparation 
for embolization is not bundled with the embolization code and is separately reportable. In this case, there is 
documentation that a visceral angiogram was performed with satisfactory descriptors to justify coverage. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision 
and interpretation provided to the enrollee on July 2, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on August 30, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you should not be charged for the eye refraction 
as you are already being charged for the office visit. The Plan denied your request. The Plan says the benefit is 
exhausted as you had an eye refraction on February 14, 2022. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
these services when once per calendar year. 
 
We looked at the file and the Plan's rules. The file shows that you have exhausted the vision benefit. Therefore, 
we decided that the Plan does not have to pay for an eye refraction provided on August 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 31298, 31295, and 31254 billed for date of 
service June 2, 2022. 
 You asked the Plan to pay for procedure codes 31298, 31295, and 31254. 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 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 codes 31298, 31295, and 31254 is 1. The MAI value for this code is 2. You 
billed 2 units of each of these codes, exceeding the MUE. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 31298, 31295, and 31254 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 31298, 31295, and 31254 billed for date of service June 2, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on May 03, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that we depend upon the facility staff to verify 
eligibility and to obtain authorization. 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 a nursing facility visit 
provided on May 03, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 04, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
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 laboratory services 
provided on June 04, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
documentation does not support that the requested ventilator is medically reasonable or necessary. Our physician reviewer found the enrollee has severe COPD.  There is no arterial blood gas (ABG), done while 
stable, showing chronic carbon dioxide retention. If the enrollee does have chronic CO2 retention, may benefit 
from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during 
sleep. This has not been tried and failed. Medicare does not cover a home ventilator when used as BiPAP. 
Therefore, the enrollee does not meet criteria for the requested 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplementary benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve the benefits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the need for this request was not met because there is not a high risk for hospitalization. 
 The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file, our physician's review, and the Medicare rules. Based on this information, we decided 
that Medicare rules for coverage of the benefits have not been met. Specifically, our reviewer found that 
although the enrollee is listed as chronic obstructive pulmonary disease (COPD) (emphysema), which is one of 
the covered chronic conditions, insufficient evidence was provided show that you meet the criteria for being a 
high risk for hospitalization. There were no other exceptional circumstances provided to support this request. 
Therefore, we decided that the Plan does not have to pre-approve special supplementary benefits for the 
chronically ill (SSBCI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for prolia injection provided on July 22, 2022. 
 
You asked the Plan to waive the coinsurance for prolia injection. You say that you say that your coinsurance 
amount should be $80. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for prolia injection. This item/service falls within the Medicare 
Part B prescription drugs 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 coinsurance for prolia 
injection provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing - four or more teeth per 
quadrant (D4341). 
 
You asked the Plan to pre-approve the periodontal scaling and root planing - four or more teeth per quadrant 
(D4341). You say that the service requested is medically necessary. The Plan denied your request. The Plan 
says that this service is not medically necessary. 
 
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. The Plan covers the 
periodontal scaling and root planing - four or more teeth per quadrant (D4341) when the services are medically 
necessary and reasonable. 
 
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 periodontal scaling and root planing 
- four or more teeth per quadrant (D4341). Our reviewer says that the service is medically necessary. Our 
physician reviewer found on review of the documentation provided, the record indicates the presence of bone 
loss and subgingival calculus deposits. Scaling and root planing is medically reasonable to treat the enrollee's 
periodontal disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the periodontal scaling and root planing - four or more teeth per quadrant 
(D4341) have been met. Therefore, we decided that the Plan has to pre-approve periodontal scaling and root 
planing - four or more teeth per quadrant (D4341).  
 
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.