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

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from September 6, 
2021, to September 7, 2021. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the submitted records do not support the billing of DRG 062. 
 
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 062. 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 these services. Our reviewer says that the submitted records do not support the 
billing of DRG 062. Our physician reviewer found the enrollee presented to the emergency department (ED) 
with right-sided weakness. Computed tomography angiography (CTA) was negative for vessel occlusion and 
CT showed age indeterminate infarction in the left corona. She left against medical advice. There is no 
documentation indicating that the enrollee's obesity had any direct impact on her care. The records do not 
support the billing of DRG 062.  
 
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 the inpatient hospital services rendered from September 6, 2021, to September 7, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve percutaneous implantation of neurostimulator electrode array, 
epidural (CPT code 63650). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the request is not medically necessary because the enrollee's records show that they 
have not had include a psychological evaluation to determine if the enrollee is a suitable candidate for a spinal 
cord stimulator. 
 
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 services. Our physician reviewer 
found the documentation supports that the coverage criteria for the percutaneous implantation of 
neurostimulator electrode array have been met in this case. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650).   
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 February 15, 2022, billed 
with codes 81201, 81295, 81298, 81317, 81403, 81404, 81405, 81406, 81407, 81408, and 81432. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the claim has not been billed as 
required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 15, 2022, billed with codes 81201, 81295, 81298, 81317, 81403, 81404, 81405, 81406, 81407, 81408, 
and 81432.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric scooter (E1230). 
 
You asked the Plan to pre-approve an electric scooter. You say that the electric scooter is necessary. The Plan 
denied your request. The Plan says the requested scooter is not medically necessary. There is nothing to show 
you cannot use a standard wheelchair for mobility. 
 
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 an electric scooter. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found clinical documentation shows that 
you have mobility or gait impairment but does not show you would not be able to complete self-care 
tasks/ADLs with a manual wheelchair or custom manual wheelchair. There is also no information to show that 
you can safely operate a power scooter thus medically unnecessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electric scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an electric scooter (E1230).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting inpatient rehabilitation for the 
enrollee. The Plan denied your request. The Plan says that rules for IRF care have not been met. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found although respiratory failure and heart failure decompensation are not IRF compliant diagnosis', clinical 
documentation shows that the enrollee is very medically complex and would be expected to require close 
medical monitoring on an inpatient basis. Evaluating provider states that enrollee requires intense therapy and 
would be able to tolerate 3hrs of therapy per day. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 drug testing services (G0483) provided on December 9, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. 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 drug testing services (G0483) provided on December 9, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve meal plan services (S5170). 
 
You asked the Plan to pre-approve the meal plan services. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage rules for this benefit have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services 
include services to improve the functioning of a malformed body member. This service is not covered under 
Medicare rules. The plan provides a supplemental benefit for this service for beneficiaries that have been 
discharged from the hospital due to congestive heart failure. 
 
We looked at the file and Medicare rules. The records do not show a hospital admission for congestive heart 
failure. Based on this information, we decided that Medicare rules for coverage of the meal plan services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve meal plan services (S5170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on November 10, 2021. 
 
You asked the Plan to pay for the provided services. You say that the enrollee was treated for venous 
insufficiency and post-surgical lymphedema. The Plan denied your request. The Plan says the medical records 
do not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications.  
 
We looked at the file and Medicare rules. The medical documentation does not show that the enrollee has 
lymphedema or chronic venous insufficiency. As the base code is not covered for the enrollee in this case, the 
related accessories are also not covered. 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 the pneumatic 
compression device and related supplies provided on November 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta injections. 
 
You asked the Plan to pre-approve Zilretta injections. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Zilretta injections. Our reviewer says 
that the documentation does not support that the requested drug is medically reasonable or necessary. Our 
physician reviewer found you have pain related to osteoarthritis of the left knee, diagnosis confirmed with 
imaging studies. You received a Zilretta injection in the left knee on June 23, 2020 and on July 6, 2021. The 
efficacy and safety of repeat administration of Zilretta have not been demonstrated. Therefore, you do not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Zilretta injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive oral evaluation (D0150), intravenous 
moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and intravenous moderate (conscious) 
sedation/analgesia - each subsequent 15-minute increment (D9243). 
 
You asked the Plan to pre-approve dental services. You say that the enrollee cannot receive dental care without 
sedation. You say that more issues are arising due to time it took to locate a provider who would offer this 
service. The Plan denied your request. The Plan says the enrollee had comprehensive periodontal evaluation 
(D0180) on March 31, 2022, therefore the benefit has been exhausted. In addition, the sedation is only covered 
when done as part of a covered service. 
 
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. Supplemental dental services 
benefit includes periodontal and comprehensive oral evaluation  1 procedure code every 3 calendar years and 
anesthesia  as needed with covered procedures to include intravenous moderate (conscious) 
sedation/analgesia.  
 We looked at the file, the Plans rules, and Medicares rules. You previously received covered comprehensive 
periodontal evaluation on March 31, 2022. The periodontal exam and comprehensive oral evaluation fall within 
the exams benefit which has been exhausted. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive oral evaluation (D0150), intravenous moderate (conscious) sedation/analgesia- first 15 minutes 
(D9239) and intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment 
(D9243).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care, per day, for the evaluation and 
management of a patient (CPT code 99233-57) provided on April 15, 2022. 
 
You asked the Plan to pay for the service. You say that the code is separately payable, and you would like the 
claim reprocessed for payment. The Plan denied your request. The Plan says the service is not covered as 
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.  
This procedure is bundled as part of the global surgical fee because it was reported within global period of the 
minor surgical procedure, debridement including removal of foreign material at the site of an open fracture 
and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and 
bone (CPT code 11012) that was billed for the same date of service by same provider. A modifier was not 
billed on the claim to represent the services as separate/distinct. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care, per day, for the evaluation and management of a patient (CPT code 
99233-57) provided on April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on April 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 7, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 75625. We decided that the Plan does not have to pay 
for procedure code 75716.  
 
You asked the Plan to pay for procedure codes 75625 and 75716. You say that the documents should be 
reviewed, and the codes should be processed for payment. The Plan says that procedure code 75625 is not 
supported by the medical records submitted. The Plan also says procedure code 75716 is considered inclusive 
to procedure code 37226. 
 
We decided that the Plan has to pay for procedure code 75625.  
 
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 procedure code 75625. Our reviewer says that the medical 
records describe the procedure performed, which supports the use of procedure code 75625. Therefore, we 
decided that the Plan has to pay for procedure code 75625.  
 
We also decided that the Plan does not have to pay for procedure code 75716. 
 
In this case, we have confirmed that code 75716 is a column II code to column I code 37226; however, 75716 
was billed with a modifier. 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 procedure code 75716. 
Our reviewer says that modifier 59 would not be appropriate to bill as the code description is included with 
code 37226. Therefore, we decided that the Plan does not have to pay for procedure code 75716. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate.  
 
   
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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of your out-of-pocket costs 
before the exam and treatment. The Plan denied your request. The Plan says your benefit for the requested item 
or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 10, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on May 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel the member needs inpatient rehab as the 
rehab faculty says they can help the member with a walking scooter and walker. The Plan denied your request. 
The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the 
requirements for approval. 
 
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 is at a level of function which does not require intensive therapy. The 
enrollee is at an appropriate level of care and may receive appropriate level of rehabilitation services without 
admission to an IRF.  
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 an IRF admission and services.