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

 
We decided that the Plan has to pay for insertion of new or replacement of permanent pacemaker with 
transvenous electrode(s); atrial and ventricular (CPT code 33208) provided on January 14, 2022. 
 
You asked the Plan to pay for the services. You say that you are asking for the claim to be paid because the 
enrollee's right atrial and right ventricular leads were replaced due to "noise on both leads". The Plan denied 
your request. The Plan says that per the manufacturer, these leads are covered under a lifetime warranty. The 
Plan states they did not see any indication in the records provided for the Plan's review that available credit was 
requested from the manufacturer. The Plan states even if the provider chooses to use a new vendor, they still 
must report the credit (whether it was received or not) from the original vendor. 
 
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 Plans denial is predicated on a warranty being in effect. As a result, the 
Plan has the obligation of proving such warranty exists and that it applies in this case. By failing to supply 
warranty information, the Plan has not met that burden. Therefore, we decided that the Plan has to pay for 
insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular 
(CPT code 33208) provided on January 14, 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 pre-approve a referral for care and treatment to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a referral for care and treatment to be provided by an OON provider. You 
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral for care and treatment to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95806 billed for date of service November 5, 
2021. 
 
You asked the Plan to pay for procedure code 95806. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says this claim must be submitted to the enrollee's primary 
insurer before payment can be made. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for procedure code 95806 until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for procedure code 95806 billed for date of service November 5, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
June 26, 2021, to June 30, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation does not support the coding. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the billed services. Our reviewer found that the enrollee has a 
medical history including hypertension, dementia, anemia and multiple falls who was admitted to the skilled 
nursing facility after a right-sided hip replacement. The documentation indicates she was medically stable. The 
5-day MDS assessment indicates that the member has an active diagnosis of lung disease (asthma, chronic 
obstructive pulmonary disease, or chronic lung disease). The documentation does not support the correct 
PDPM was submitted. There is no indication that the enrollee had active lung disease or that the 4th 
alphanumeric character in the PDPM was correct. The partial adjustment to PDPM AFUF1 was appropriate. 
 
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 billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided from June 26, 2021, to June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) from an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you have requested treatment from this provider 
for many years. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an epidural steroid injection (ESI) from an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 12, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the patient had multiple exams on this date 
of service. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service October 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93312, 93320, and 93325, billed for date of 
service August 18, 2022. 
 You asked the Plan to pay for the billed services. You say that the procedure is not bundled to another 
procedure. The Plan denied your request. The Plan says payment for code 93312 is bundled into payment for 
code 01926. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
In this case, we have confirmed that code 93312 is a column II code to column I code 01926. Code 93312 was 
not billed with an appropriate modifier to bypass the edit. Because primary procedure 93312 is not payable, the 
add-on codes 93320 and 93325 are also not covered. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 93312, 93320, 
and 93325, billed for date of service August 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11103 billed for date of service May 5, 2022. 
 
You asked the Plan to pay for procedure code 11103. The Plan denied your request. The Plan says payment for 
code 11103 is bundled into payment for code 17110. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 11103 is a column II code to column I code 17110. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 11103 billed for date of service May 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
November 29, 2021 to December 2, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
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 DRG 689. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the review has determined that the documentation did not support diagnosis code I21.A1 - myocardial 
infarction, type 2. The records support using DRG 690. A review of the medical record found no cardiac 
imaging to evaluate for new ischemic changes. There was no cardiology consult noted and no treatment for the 
condition.  
 
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 to the enrollee from November 29, 2021 to December 2, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for reinsertion of spinal fixation device provided to the enrollee on 
September 10, 2021. 
 
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 requested service code is not substantiated by the clinical documentation. 
 
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 22849 is "Reinsertion of spinal fixation device." 
 
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 the procedure details cite a blunt 
dissection was taken to explore the prior fusions at C4-5 and after the scar tissue was mobilized from the plate 
and the tracheoesophageal fascia was mobilized medially, the prior Medtronic plate was removed. After this, 
an annulotomy was done at the appropriate level. Thorough discectomy was done with the pituitary. A partial 
corpectomy at C4-5 level around the disc space down to the posterior cortex was performed. The posterior 
osteophytes were drilled down to the posterior longitudinal ligament and then opened. Wide foraminotomies 
were done bilaterally and the disc herniations were removed. An interbody graft was tapped into the 
corpectomy site. Distraction pins were removed and an anterior plate was placed over the construct. Screws 
were placed at the appropriate level above and below the corpectomy site and locked with a locking 
mechanism. Therefore, the records do support that CPT 22849: reinsertion of spinal fixation device was a 
separate and distinct procedure from CPT 22855: removal of anterior instrumentation. 
 
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 
reinsertion of spinal fixation device provided to the enrollee on September 10, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac catheterization (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 cardiac catheterization. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that radionuclide stress test in January 2023 was negative for ischemia. Guidelines would not 
support the necessity of the requested invasive procedure in the enrollees clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93458).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen generator machine (E1392). 
 
You asked the Plan to pre-approve a portable oxygen generator machine. You say that this item is medically 
necessary. The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen generator machine 
Our reviewer says that this item is not medically necessary. Our physician reviewer found there is no indication 
your current oxygen equipment is not meeting your medical needs or ADLs in or around the home. You have 
not been evaluated by Respiratory Therapy for a portable oxygen concentrator and have not trialed or failed an 
oxygen conserving device with lightweight tanks. Additionally, you are using 5lpm of oxygen and an oxygen 
bleed for his CPAP, which are both contraindicated per Medicare for coverage of a portable oxygen 
concentrator. 
 
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 portable oxygen generator machine have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a portable oxygen generator machine (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 sensor. You say that the enrollee qualifies for a Freestyle 
Libre 2 sensor. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 24, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on May 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0279) provided on August 1, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the add-on code was 
not billed with a primary procedure code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the 
services is an add-on code and has not been billed with an appropriate primary procedure code. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the services (G0279) provided on August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service May 31, 
2022. 
 
You asked the Plan to pay for procedure code 93971. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 93971 is bundled into payment for code 36475. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93971 
is a column II code to column I code 36475. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 93971 billed for date of service May 31, 2022.