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

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from February 7, 2021, 
to February 20, 2021, as billed with Diagnosis Related Group (DRG) 441. 
 
 You asked the Plan to pay for inpatient care billed with DRG 441. You say that these services were medically 
necessary and are supported as billed. The Plan denied your request. The Plan says DRG 441 is not supported 
as the diagnosis of toxic encephalopathy (G92) is not supported in the record. The Plan argues that DRG 442 is 
more appropriate in this case. 
 
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. DRG 441 requires a diagnosis of toxic encephalopathy 
(G92). 
 
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 inpatient care billed with DRG 441. Our 
reviewer says that the services are not supported with the DRG billed. Our physician reviewer found that the 
documentation provided does not sufficiently support a diagnosis of toxic encephalopathy. The enrollee 
presented to the emergency department with right side pain, was admitted to observation status, then admitted 
to inpatient status for reassessment, and the enrollee did not feel comfortable with discharge. During the 
hospital stay, Thrombocytopenia became the primary diagnosis due to worsening condition. On February 11, 
2021, the consult note documents encephalopathy, and a consult note with no date of service documents acute 
encephalopathy and toxic encephalopathy. No other documentation was found to support the treatment and care 
for encephalopathy, acute encephalopathy or toxic encephalopathy. The discharge note does not mention 
encephalopathy. Although, encephalopathy is documented, reasonable consistent documentation throughout 
hospital stay, was not found and therefore, is not supported as a diagnosis for hospital admission. The 
documentation does support mental status deterioration, and in this case a query would be made before 
submitting the claim. The services are not supported as billed with a diagnosis of toxic encephalopathy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 441 have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospital care provided from February 7, 2021, to February 
20, 2021, as billed with Diagnosis Related Group (DRG) 441.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on August 22, 
2020. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee was admitted 
to hospice care upon discharge. You also say that this was not related to the enrollee's hospice admission. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on August 22, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 9. 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496. 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 9. 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vagus nerve stimulator for the enrollee. 
 
You asked the Plan to pre-approve a vagus nerve stimulator. You say that the requested vagus nerve device is 
medically necessary for this enrollee. The Plan denied your request. The Plan says the Medicare coverage 
criteria are not met. 
 
The Plan must follow Medicare rules. Medicare has very specific coverage criteria for a vagus nerve 
stimulator. We asked our Medical Director to carefully review the case file and the additional information 
submitted by your office and apply the relevant Medicare rules to determine if the Plan was correct in denying 
the request to pre-approve a vagus nerve stimulator. Our Medical Director says that the Medicare coverage 
criteria are not met. Our Medical Director states that at issue is coverage for a vagal nerve stimulator. The 
medical records provided show the enrollee is a 70-year-old woman with a diagnosis of Major depressive 
disorder, recurrent severe, without psychotic features. The Plan denied coverage stating Under the Medicare 
guidelines this request does not meet the criteria for coverage because the submitted documentation does not 
indicate that the enrollee is currently experiencing a major depressive episode as measured by a guideline 
depression scale assessment tool on two visits within a 45-day period. 
 The records further show the enrollee is in a qualified clinical study for treatment-resistant depression. The 
enrollee underwent a screening for the Recover trial on February 9, 2022. Neither the records provided in the 
case file nor the additional records provided during our review contain documentation of completion of a 
guideline-recommended depression scale assessment tool on two visits, within a 45-day span prior to 
implantation of the VNS device. Consequently, it has not been established that the required coverage criteria as 
established by the Medicare NCD 160.18, have been met in this case.  
 
We looked at the Medical Directors review, the file, the additional information and Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of a vagus nerve stimulator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a vagus nerve stimulator for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that the requested drug will be more effective. The Plan 
denied your request. The Plan says step therapy requirements have not been met. 
 
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 Ilumya. Our reviewer says that the 
requirements for coverage of Ilumya have not been met. Our physician reviewer found the Plan requires a trial 
of Avsola, Inflectra, and Renflexis before they will approve the requested drug. In this case, the patient has not 
tried and failed the required drugs. There is no documentation provided indicating that the Plans required 
drugs would likely be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional home health physical therapy services 
(G0151). 
You asked the Plan to pre-approve additional home health physical therapy services. You say that this care is 
medically reasonable and necessary. The Plan denied your request. The Plan says additional home health 
physical therapy visits beyond what have been approved are not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health physical therapy 
services. Our reviewer says that the requested additional home health physical therapy visits are not medically 
reasonable and necessary. Our physician reviewer found that the enrollee is a 94-year-old female with a history 
of hypertension. The enrollee started receiving home health services in February 2022. Based on the 
documentation provided, the enrollee does not have documented, ongoing, home health skilled physical 
therapy needs. The enrollee is functioning at a level commiserate with a lower level of care. As such, the 
requested, ongoing, home health physical therapy is not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health physical therapy services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 6 additional home health physical therapy services 
(G0151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the immediate denture - mandibular 
(D5140) provided October 28, 2021. 
 
You asked the Plan to provide additional payment for the immediate lower denture. You say that you would 
like the claim covered. The Plan denied your request. The Plan says the cost sharing has applied correctly. 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 immediate 
lower denture with 40% coinsurance.  
 
We looked at the file and Medicare rules. You have been asked to pay $325.77 ($814.44 allowed amount x 
40% coinsurance = $325.77). 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 provide additional payment for the immediate 
denture - mandibular (D5140) provided October 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities (97530) provided on April 26, 2021. 
 
You asked the Plan to pay for therapeutic activities. You say that these services were necessary and were billed 
appropriately. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 92526 and 97530. This PTP edit has a modifier indicator of 
1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed as required by Medicare coding regulations. 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 97530 
is a column II code to column I code 92526. 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 therapeutic activities (97530) provided on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), electronic connection 
(E2311), expandable controller harness (E2313), bracket center mount footplate, gel arm pads and a power seat 
elevation feature. 
 
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that these items cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical 
purpose. Medicare rules also say that a power seat elevation feature is non-covered because it is not primarily 
medical in nature. Medicare rules say that providers must report services correctly. Providers must report 
services with the appropriate CPT code. 
 
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 expandable controller, electronic 
connection and expandable controller harness. Our reviewer says that the expandable controller, electronic 
connection and expandable controller harness are not considered medically reasonable and necessary in this 
case. You have 3 power options of tilt, recline, and power elevating leg rests but you do not need to control the 
power options through a joystick. Your upper extremity strength supports that you can control any power 
options through their own switches. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of an expandable controller, electronic connection and expandable controller harness. 
 
We looked at this physician's review, the file, and Medicare rules. The gel arm pads and a power seat elevation 
feature at issue in this appeal do not serve a purpose that is primarily medical in nature. In this case, the CPT 
Code Manual definition of code K0108 is wheelchair component or accessory, not otherwise specified. We find 
that CPT code K0108 is not supported in the medical record. Specifically, footplates are being miscoded with 
K0108 as there are specific CPT codes for footplates. Based on this information, we decided that Medicare 
rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller (E2377), electronic connection (E2311), expandable controller harness 
(E2313), bracket center mount footplate, gel arm pads and a power seat elevation feature.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
16, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 16, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on September 13, 2021. 
 
You asked the Plan to pay for the gingival irrigation. You say that you would like to appeal this service. The 
Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pay for the 
gingival irrigation (D4921) provided on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and four 
additional intraoral periapical x-rays (D0230 x4) provided on June 2, 2021. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that you feel you should not be held 
responsible for the payment for these services. The Plan denied your request. The Plan says these services are 
not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pay for the first 
intraoral periapical x-ray (D0220) and four additional intraoral periapical x-rays (D0230 x4) provided on June 
2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and implant 
supported porcelain/ceramic crown (D6065). 
 
You asked the Plan to pre-approve the custom fabricated abutment and implant supported porcelain/ceramic 
crown. You say that these services are medically necessary. You also say that the sales representative assured 
you that these services would be covered completely. The Plan denied your request. The Plan says these 
services are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom fabricated abutment (D6057) and implant supported porcelain/ceramic crown (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two removals of torus mandibularis (D7473 x2) and 
therapeutic parenteral drugs (D9612) provided on October 18, 2021. 
 
You asked the Plan to pay for the removals of torus mandibularis and therapeutic parenteral drugs. You say that 
you would like to appeal these services. The Plan denied your request. The Plan says these services are not 
covered benefits under the enrollee's dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pay for the two 
removals of torus mandibularis (D7473 x2) and therapeutic parenteral drugs (D9612) provided on October 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve microsurgical techniques, requiring use of operating 
microscope (List separately in addition to code for primary procedure) (CPT code 69990). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says CPT code 69990 should not be reported with other procedures even if an operating 
microscope is used. 
 
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 Code 69990 is included in the other listed coeds for this case. It should not be unbundled and 
billed as a separate code.  
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 microsurgical techniques, requiring use of operating microscope (List separately in 
addition to code for primary procedure) (CPT code 69990).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided on July 23, 2021. 
 
You asked the Plan to pay for medical nutrition therapy services. The Plan denied your request. The Plan says 
medical nutrition therapy (MNT) is covered by Medicare only for diabetes, renal disease, or for non- 
functioning structures that normally permit food to reach the stomach and digestive tract. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services provided on July 23, 2021.