Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve Prednisone. The Plan denied your request. The Plan says this drug is not 
covered under the enrollee' Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has multiple medical 
concerns that can be safely managed at the LTACH level of care. The Plan denied your request. The Plan says 
criteria for admission to the LTACH have not been met. 
 
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 appears to be more stable and improving and should only require short-
term additional acute care services that can safely be provided at the current facility. Transfer to the LTACH 
would not be clinically advantageous at this time and completion of treatment at the current facility is 
recommended.  
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93010 billed for date of service March 23, 2022. 
 
You asked the Plan to pay for code 93010. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 11, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 93010 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 93010 billed for date of service March 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service October 12, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service October 12, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 3, 
2022. 
 
You asked the Plan to pay for procedure code 76641. 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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
30, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. 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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 11, 2022, to 
July 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that only one NOA is required per 
admission and the claim should be processed for payment. The Plan denied your request. The Plan says the 
claim has not been billed with the correct admission date. 
  The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 11, 2022, to July 
10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99152 and 99153 provided on March 24, 
2022. 
 
You asked the Plan to pay for procedure codes 99152 and 99153. You say that the medical records support the 
billing of codes 99152 and 99153. The Plan denied your request. The Plan says the medical records do not 
support the billing of codes 99152 and 99153. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
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 99152. Our reviewer says that the medical 
records do not support the billing of code 99152. The record does not state that a trained independent observer 
was present for the duration of the moderate sedation. This is a required component to report 99152. 
 
Additionally, the review shows that the medical records provided represent professional charges; however, 
procedure code 99153 was provided in a facility with a place of service code of 21. Procedure code 99153 has a 
PC/TC Modifier Status of 3, which specifies a Technical Component only code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99152 and 99153 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99152 and 99153 provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) office visits with an orthopedic surgeon to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits with an orthopedic surgeon. You say that you would like to see 
this doctor as a follow up to a surgery performed in 2017. The Plan denied your request. The Plan says you 
must use network providers to get your medical care and services. The only exceptions are emergencies, 
urgently needed services, and out-of-area dialysis services. Your services do not meet these exceptions. The 
services you are requesting are available in your area. 
 
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 
twelve (12) office visits with an orthopedic surgeon to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 5, 2022, billed with 
codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81351, 81406, 
81437 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
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 
July 5, 2022, billed with codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 
81321, 81334, 81351, 81406, 81437 and 81479.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
28, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that You did not provide a specific argument 
with your appeal request. 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 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed a unit with the LT modifier and a unit with the RT modifier 
instead of the required bilateral modifier on a single line item. Based on this information, we decided that 
Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 76641 billed for date of service September 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy, flexible; with biopsy, single or multiple 
(45380) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a colonoscopy. You say that the enrollee is sick and needs this procedure 
done. The Plan denied your request. The Plan says the enrollee must use network providers to get medical care 
and services. There are in-network providers available for this service. 
 
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 colonoscopy, flexible; with biopsy, single or multiple (45380) to be provided by an out-of-network (OON) 
provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 7, 2022, to 
February 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you were not made aware of the 
change switching to NOAs from a Request for Anticipated Payment. You say that due to the 
miscommunication in the process change, the claim should be reconsidered for payment. The Plan denied your 
request. The Plan says the claim has not been billed with the correct admission date. 
  The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue and 
the admission date on the NOA are incorrect. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from January 7, 2022, to February 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor (95250). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the enrollee is no longer using insulin; therefore, the enrollee does 
not meet criteria for approval of the requested sensor. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 continuous glucose monitor (CGM) sensor (95250).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 30, 2022, to 
June 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 30, 2022, to June 
28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 15, 2022, to 
February 23, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the DRG billed is not supported. 
 
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 E43, defined as unspecified severe protein-calorie 
malnutrition). We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the diagnosis 
billed. Our physician reviewer found although the diagnosis of severe protein calorie malnutrition is 
documented in the gastroenterology progress note and discharge summary, sufficient supporting documentation 
was not found within the medical record to validate this diagnosis based on clinical criteria. The enrollees 
weight at discharge was 61.8kg with a documented weight loss from 67 kg on August 5, 2021. Weight loss was 
7.7% within the past 6 months and BMI was 23. Progress notes on February 21 states "body fat and muscle 
mass are normal". While an estimated energy intake of less than 50% of enrollee's requirement for greater than 
one month was documented both phenotypic criteria and etiologic criteria must be met for a diagnosis of severe 
protein-calorie malnutrition. The review has determined that the documentation did not support E43 
(Unspecified severe protein-calorie malnutrition). Therefore, the diagnosis billed is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 15, 2022, to February 23, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
pneumatic appliance, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the enrollee 
would face obstacles that would impair healing if forced to use a tactile device due to its complication of 
applying the garment. The Plan denied your request. The Plan says the medical record shows the enrollee only 
has swelling in her legs and does not have any swelling in her trunk or belly. The items the enrollee asked for 
are not medically necessary under her Medicare because her records show she only has lymphedema in her 
extremities. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a pneumatic appliance, full leg (E0667).