Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has COPD/resp failure/not 
OSA. She has failed BiPAP. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD, documented 
with pulmonary function tests and imaging.  However, there is no ABG done while stable to document chronic 
CO2 retention. ABG results are provided from 7/31/22, consistent with acute on chronic hypercarbic 
respiratory failure. However, the enrollee's circumstances at that time are not provided. The enrollee was 
reportedly on BiPAP which "failed", but a subsequent ABG the same day showed a normal PaCO2. The 
enrollee's hemoglobin dropped substantially the same day, suggesting a non-pulmonary acute event. If this 
enrollee does have chronic CO2 retention, she may benefit from BiPAP with AVAPS during sleep as an 
outpatient. There is no evidence this has been tried and failed as an outpatient. Medicare does not cover a home 
ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from June 5, 2022, to June 30, 
2022. 
 
You asked the Plan to pay for the inpatient services. You say that you have provided records to support 
payment. The Plan denied your request. The Plan says you did not bill with the correct revenue code or 
occurrence code for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that leaves of absence from an inpatient stay must be 
billed with revenue code 018x.. The records you provided clearly state that the patient left the facility to 
participate in a medical trial.  However, you did not bill with revenue code 018x to indicate this leave of 
absence from the inpatient facility as is required. We looked at the file and Medicare rules. Therefore, we 
decided that the Plan does not have to pay for inpatient services provided from June 5, 2022, to June 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for Durable medical equipment (DME), 
Medicare Part B prescription drugs, outpatient diagnostic tests and outpatient surgery provided from provided 
on June 15, 2021 
 
You asked the Plan to waive the cost-share for DME, Medicare Part B prescription drugs, outpatient diagnostic 
tests and outpatient surgery. You say that you disagree with the cost-share. 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 20% 
coinsurance durable medical equipment (DME), a 20% coinsurance for Medicare Part B prescription drugs, a 
$10 copayment and a $15 copayment for outpatient diagnostic tests and a $325 copayment for outpatient 
surgery.  
 
You have been asked to pay a 20% coinsurance for DME, a 20% coinsurance for Medicare Part B prescription 
drugs, a $10 copayment and a $15 copayment for outpatient diagnostic tests a $325 copayment for and 
outpatient surgery. The total amount for DME is $969.70. The total allowed amount for the prescription drugs 
is $188.99. The total amount for surgical supplies $14.52. The total amount for diagnostic test is $25. The total 
amount you are being asked to pay for surgery services is $300 which is less than the required amount. The 
total amount you are being asked for all services rendered is $1,498.21 ($188.99 + $969.70+ $14.52 + $25 +$ 
300 = $1498.21). 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 cost-share for Durable medical equipment 
(DME), Medicare Part B prescription drugs, outpatient diagnostic tests and outpatient surgery provided from 
provided on June 15, 2021
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45385 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 45385. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 45385 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 45385 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 45385 billed for date of service July 27, 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 exhibits global weakness resulting in 
deficits in balance, strength, functional mobility, bed mobility, transfers, activities of daily living, 
coordination/proprioception, impaired safety awareness, range of motion, and ambulation. The Plan denied 
your request. The Plan says the enrollee does not meet the guidelines for medical necessity because their 
medical condition requires further evaluation and treatment in the current acute care hospital. 
 
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 medically necessary care can be provided safely in a different level of care. There is 
not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87086) provided on July 5, 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 the claim cannot be paid 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. 
 
We find that CPT code 87086 is not supported in the medical record. Specifically, the claim was not billed with 
a valid primary diagnosis code per National Coverage Determination (NCD): Urine Culture, Bacterial 190.12. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (87086) provided on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D2950). 
 
You asked the Plan to pre-approve the dental service (D2950). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services 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 the 
dental service (D2950).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code S2900. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 8, 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 (E0730), provided on February 22, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the item is not covered when provided by a chiropractor. 
 
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 transcutaneous electrical nerve stimulation (TENS) device (E0730), 
provided on February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code L0648 billed for date of service August 31, 2022. 
 
You asked the Plan to pay for code L0648. You say that you have provided all documentation to support 
payment. The Plan denied your request. The Plan says you did not provide an accurate date of service on the 
claim you submitted. 
 
The Plan must follow Medicare rules. The rules state that the date of service can either be entered as the 
shipping date of the item or the date of delivery to the patient. In this case, you billed with a date of service of 
August 31, 2022. However, the shipment date on the statement from FedEx was August 22, 2022, and the 
delivery date was August 27, 2022.  Neither of these dates matches the date of service billed. Therefore, we 
decided that the Plan does not have to pay for code L0648 billed for date of service August 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on March 4, 2022. 
 
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 procedure code 20985 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 20985 is computer-assisted surgical navigational 
procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary 
procedure. 
 
We find that CPT code 20985 is not supported in the medical record. Specifically, the operative report does not 
document that the servicing provider performed the procedure. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the surgical services rendered on March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the morphometric analysis, in situ hybridization (quantitative 
or semi-quantitative) each probe (88377) provided May 20, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please let the attached documentation serve 
to support medical necessity of the testing performed. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. 
 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 morphometric analysis, in situ hybridization (quantitative 
or semi-quantitative) each probe (88377) provided May 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99284 and 99053 provided on August 28, 
2022. 
 
You asked the Plan to pay for procedure codes 99284 and 99053. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that physicians in the same group practice who are in 
the same specialty must bill and be paid as though they were a single physician. 
 
We find that CPT code 99284 is not supported in the record. Specifically, the record indicates that CPT code 
99284 has been processed and paid to a different provider in the same group with the same specialty on the 
billed date of service.  
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate procedure code. We find that procedure code 99053 has a status indicator of B on the Physician Fee 
Schedule. This means that procedure code 99053 is not separately payable. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99284 and 99053 provided on 
August 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal aortic aneurysm (AAA) screening (76706) 
provided on August 4, 2022. 
 You asked the Plan to pay for an AAA screening. You say that this test was medically necessary and was 
ordered by the enrollee's treating physician. The Plan denied your request. The Plan says the criteria for 
coverage of this screening are not met in this case. 
 
The Plan follows Medicare rules. The rules say that payment may be made for a one-time ultrasound screening 
for AAA for beneficiaries who meet certain criteria. 
 
We looked at the file and Medicare rules. There is insufficient information in the case file to show that the 
enrollee is in one of the qualifying risk categories. We cannot confirm that the criteria for coverage of this 
screening have been met in this case. In addition, the diagnosis billed on this claim indicates that this was not 
provided for screening purposes. Therefore, we decided that the Plan does not have to pay for an abdominal 
aortic aneurysm (AAA) screening (76706) provided on August 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
July 5, 2022. 
 
You asked the Plan to pay for the Guardant Reveal test. You say that please note that the Guardant Reveal 
molecular diagnostic test at the request of the ordering physician. The Plan denied your request. The Plan says 
this test is considered experimental and investigational and not covered by Medicare per DEX Diagnostics. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant Reveal test have not been met. Therefore, we decided that the Plan does not have to 
pay for the unlisted molecular pathology procedure (81479) provided July 5, 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 you need to continue the right path and have 
therapy/rehabilitation to keep up with your function and mobility so you may care for yourself and to regain 
strength and mobility. The Plan denied your request. The Plan says the records do not show that you need an 
intensive team or need to be seen by a rehabilitation doctor at least 3 times a week, these services may be 
provided safely in other settings, for example, a skilled nursing facility. 
 
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 medically necessary care may be safely provided in a different level of care. There is 
not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on June 24, 2022. 
 
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 services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes.  
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services rendered on June 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies rendered on June 11, 2022. 
 
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 procedure code A4595 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 A4595 is electrical stimulator supplies, 2 lead, per month, 
(e.g., tens, nmes). 
 
We find that CPT code A4595 is not supported in the medical record. Specifically, the documentation does not 
support that 2 leads per month of electrical stimulator supplies were rendered. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for the electrical stimulator supplies rendered on June 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 4, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 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 October 4, 2022.