Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 21, 2021, 
through September 27, 2021, and billed with diagnosis code J18.9. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis J18.9 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of J18.9. 
 
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 secondary diagnosis code J18.9- (Pneumonia, 
unspecified organism). 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 reviewer says that the documentation does not support the secondary 
diagnosis of J18.9 Pneumonia. Our physician reviewer found that the member exhibited normal respiratory 
effort, was not in respiratory distress, but had rhonchi present on lung examination and hypoxia requiring low 
dose oxygen support. The member was diagnosed with a urinary tract infection and treated with antibiotics. No 
sputum culture results were provided. Based on the objective testing results, secondary diagnosis pneumonia, 
unspecified organism is not an appropriate secondary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 21, 2021, through September 27, 2021, and billed with 
diagnosis code J18.9.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies and transcutaneous electrical nerve 
stimulation (TENS) unit provided on September 28, 2022. 
 
You asked the Plan to pay for the durable medical equipment (DME). You say that you did not received the 
supplies or TENS unit on or before September 28, 2022. The Plan denied your request. The Plan says that 
payment cannot be made for items that were not received. 
 
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's indicate the enrollee does not believe that the items were 
received is not sufficient to refute the delivery confirmation that was included in the case file. Since no other 
rationale was provided, we find that the denial of payment is not substantiated. Therefore, we decided that the 
Plan has to pay for the electrical stimulator supplies and transcutaneous electrical nerve stimulation (TENS) 
unit provided on September 28, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 20, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56973. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for short-latency somatosensory evoked potential study, 
stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or 
head provided to the enrollee on April 13, 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 Current Procedural Terminology (CPT) code 95927-26, XS (1 unit) remains not supported, as 
there is a more appropriate code to use in this case. 
 
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  is "Short-latency somatosensory evoked potential study, 
stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or 
head." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that CPT 95927 was the best code to use in this clinical situation. The technical report corroborates that 
somatosensory evoked potential was performed. However, the sites were not recording from the central 
nervous system. The upper somatosensory evoked potential stimulation site was the ulnar nerve. The lower 
somatosensory evoked potential stimulation site is posterior tibial. Additionally, there are more appropriate 
codes to use in this clinical scenario (e.g., 95925). 
 
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 short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or 
skin sites, recording from the central nervous system; in the trunk or head provided to the enrollee on April 13, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to start working on gaining 
strength back as soon as possible. The Plan denied your request. The Plan says it is not reasonable to expect 
that the enrollee will be able to fully participate in, nor benefit from, the intensity of services of an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical or occupational therapy, and an intensive rehabilitation therapy program.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250), and deep 
sedation/general anesthesia (D9222, D9223). 
 
You asked the Plan to pre-approve removal of residual tooth roots, and deep sedation/general anesthesia. You 
say that you cannot afford the services and you want the Plan to cover them. The Plan denied your request. The 
Plan says the services at issue are not covered benefits. 
 
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 
removal of residual tooth roots (D7250), and deep sedation/general anesthesia (D9222, D9223).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that it was not the provider's fault that the claims were 
not filed timely. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until August 17, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided on 
April 11, 2022, to May 10, 2022. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that you disagree with the 
denial. The Plan denied your request. The Plan says this service does not meet this requirement of the enrollee's 
plan of benefits and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that it has not been established that a moist electric 
heating pad (E0215) or water circulating heat pad with pump (E0217) is reasonable and necessary compared to 
a standard electric heating pad (E0210). 
  
 
We looked at the file and Medicare rules. Medicare rules say that a water circulating heat pad with pump is not 
considered reasonable and necessary. Based on this information, we decided that Medicare rules for coverage 
of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan does not have 
to pay for a water circulating heat pad with pump (E0217) provided on April 11, 2022, to May 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
August 21, 2022, to August 25, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that the services were medically 
necessary and should be covered. 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 a $325 
copayment per day for days 1-5 for inpatient hospital care.  
 
 
  The file shows that you were in the hospital from August 21, 2022, to August 25, 2022. Since there is no 
copayment for the discharge date, you have been asked to pay a $325 copayment per day for days 1-4 for the 
inpatient care. The total for the stay is $1,300 ($325 copayment x 4 days = $1,300). This item/service 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 
inpatient hospital care provided from August 21, 2022, to August 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drugs coded J3490. 
 
You asked the Plan to pay for the unclassified drugs. You say that you disagree with the Plan's 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 J3490 is not supported in the medical record. Specifically, this service was billed on the 
same date of service as a surgery procedure. Without an appropriate modifier, code J3490 is considered part of 
the global surgery period. Based on this information, we decided that Medicare rules for coverage of the 
unclassified drugs have not been met. Therefore, we decided that the Plan does not have to pay for the 
unclassified drugs coded J3490.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87624 and 88175 billed for date of service 
December 13, 2021. 
 
You asked the Plan to pay for procedure codes 87624 and 88175. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says it is inappropriate to use modifier 26 with 
these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that modifier 26 is not supported for these services. Specifically, modifier 26 is used to indicate that 
the payment for the professional component of a service is requested. However, both codes 87624 and 88175 
have a professional/technical indicator of 9, which means that the concept of a professional/technical 
component does not apply. Modifier 26 cannot be used for these services. Based on this information, we decided that Medicare rules for coverage of procedure codes 87624 and 88175 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87624 and 88175 billed for date of service 
December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595), provided on 
September 15, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the clinical documentation submitted does not indicate the items 
are medically necessary. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The clinical documentation submitted does not mention the items ordered or the medical necessity 
of them. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies (A4595), 
provided on September 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed and support surface (E0261, 
E0184). 
 
You asked the Plan to pre-approve the semi-electric hospital bed and support surface. You say that these items 
are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
2. Requires attachments which can only be attached to a hospital bed; AND 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed and 
support surface. Our reviewer says that the requested bed and mattress are not medically necessary. Our 
physician reviewer found the documentation doesnt support that the enrollee has a condition that requires 
frequent positioning of the bed and mattress to alleviate pain, promote good body alignment, prevent 
contractures, or avoid respiratory infections in a way that an ordinary bed is not able to. The beneficiary has 
limited mobility due to his medical conditions. The documentation doesnt support that he has multiple stage 2 
pressure ulcers located on the trunk or pelvis and has failed to improve. 
 
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 semi-electric hospital bed and support surface have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a semi-electric hospital bed and support surface (E0261, 
E0184).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on July 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary and appropriate. 
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 (81479) provided on July 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio (J1306). 
 
You asked the Plan to pre-approve Leqvio. You say that you feel Leqvio is the appropriate therapy for the 
enrollee. The Plan denied your request. The Plan says Leqvio is a non-preferred product, and the enrollee does 
not have any stated contraindications to the preferred products. The Plan also says the enrollee has not tried any 
of the preferred agents, and a rationale for use of the non-preferred product for safety or efficacy has not been 
provided.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Leqvio. Our reviewer says that the 
enrollee does not meet the coverage criteria for Leqvio. Our physician reviewer found the provided records do 
not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred 
step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. Our 
physician reviewer also found that the requested service cannot be 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 Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio (J1306).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided from May 9, 2022, to June 8, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
supported. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the therapy services provided from May 9, 2022, to June 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87500, 87641, 87651) provided on May 
31, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services have been met. No 
clinical records were submitted to support this request. The only records provided for review were lab results. Therefore, we decided that the Plan does not have to pay for lab services (87481, 87500, 87641, 87651) 
provided on May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device billed for date of service September 15, 2022. 
 
You asked the Plan to pay for the billed services. You say that this is an accepted procedure code. The Plan 
denied your request. The Plan says the documentation did not support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The packing slip provided does not show that a TENS device 
was shipped to the enrollee. Based on this information, the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation 
(TENS) device billed for date of service September 15, 2022.