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 provided from November 26, 
2021 to December 2, 2021, 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 
would like this denial to be reconsidered. The Plan denied your request. The Plan says although the diagnosis 
of acute and chronic respiratory failure with hypoxia is documented within the medical record, sufficient 
supporting documentation was not found within the medical record to validate this diagnosis based on clinical 
criteria. 
 
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 principal diagnosis code, J96.21, defined as acute 
and chronic respiratory failure with hypoxia. 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 did not 
support J96.21. Our physician reviewer found in this case, there was no documentation of acute or chronic 
respiratory failure with hypoxia. There was no noted documentation of respiratory rates greater than 30 
(following treatment in the emergency department), use of accessory muscles, or altered mental status 
secondary to hypoxia. Our reviewer found that there was no evidence of arterial blood gases (ABGs) done to 
support an arterial oxygen pressure (PaO2) decline of 10 millimeters of mercury (mmHg) below best 
documented baseline via ABG reading. No noted persistent (more than 2 sequential consistent readings) 
decline in oxygen saturation (SpO2). Our physician reviewer also found that the appeal notes Sp02 reading of 
90% on November 28, 2021, and Sp02 of 87% on December 1, 2021, these are non-sequential readings.  
 
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 provided from November 26, 2021 to December 2, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for codes G0009 and 90677 billed for date of service June 6, 2022. 
 
You asked the Plan to pay for codes G0009 and 90677. You say that these are payable services The Plan denied 
your request. The Plan says that the units billed exceed the maximum allowed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial is predicated on a MUE rule that 
says that for codes with a MAI value of 2, only the number of units allowable in CMS's MUE chart are 
payable.  We do not disagree with this.  The MAI value for the two codes in dispute is 2, and the MUE for each 
is 1.  However, in the claims documentation that the Plan submitted in the file, there is only evidence that one 
unit of each code was billed, which does NOT exceed the MUE.  The Plan has not provided any proof that you 
have billed more units than allowed of each of these codes.  The burden is on the Plan to provide why its denial 
was correct.  By failing to provide evidence that more than 1 unit of each of the codes in dispute was billed, the 
Plan has failed to meet this burden. Therefore, we decided that the Plan has to pay for codes G0009 and 90677 
billed for date of service June 6, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 has been bedridden in the hospital for 
three months and has lost all her activities of daily living. The Plan denied your request. The Plan says the IRF 
care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as 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 the enrollee was admitted for a para-esophageal hernia repair and respiratory failure. 
The enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that the 
enrollee needs the Freestyle Libre Reader due to his diabetes. You also say that given his sensory deficits he is 
unable to check his blood sugars using a standard glucometer. The Plan denied your request. The Plan says the 
enrollee does not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for the billed code. You say that the billing is supported by chart notes. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
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.  
 
We looked at the file and Medicare rules. The file shows that the code 96372 was reimbursed by the Plan on 
August 10, 2022, with the allowed amount being applied to the enrollees responsibility. A comparison of the 
two claim lines shows these are exact duplicates. There is no evidence to support that the billed services were 
provided twice on the same date. Based on this information, we decided that the Medicare rules for the billed 
code have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 96372 
billed for date of service May 19, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64454-RT-59 billed for date of service 
December 30, 2021. 
 
You asked the Plan to pay for procedure code 64454-RT-59. You say that this code is separately payable. The 
Plan denied your request. The Plan says procedure code 64454-RT-59 is not supported in the medical record to 
allow for separate payment. It is considered inclusive to code 20611 that was also billed, and the records do not 
support the use of the 59 modifier. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code 64454-RT-59 Our reviewer 
says that procedure code 64454-RT-59 is not supported in the medical record. Our physician reviewer found 
the record supports that one joint injection was performed, which was reported with the approved CPT code 
20611. The record does not support that a separate injection in the genicular nerve was performed during this visit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64454-RT-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64454-RT-59 billed for date of service December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 29891-LT-59, 28430-LT-59, 27659-LT-59, 
and 29515-LT-59 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure codes 29891-LT-59, 28430-LT-59, 27659-LT-59, and 29515-LT-59. 
You say that the medical records support payment for these codes. The Plan denied your request. The Plan says 
procedure codes 29891-LT-59, 28430-LT-59 and 27659-LT-59 were not supported in the medical records 
submitted and procedure code 29515-LT-59 was denied as inclusive to another billed code. Code 28415--LT 
was approved. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure codes 29891-LT-59, 28430-LT-
59, 27659-LT-59, and 29515-LT-59 Our reviewer says that procedure codes 29891-LT-59, 28430-LT-59, 
27659-LT-59, and 29515-LT-59 billed for date of service May 6, 2022, are not supported in the medical record. Our physician reviewer found the use of the 59 modifier for each of these codes cannot be confirmed because 
the complete procedure report was not submitted for review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 29891-LT-59, 28430-LT-59, 27659-LT-59, and 29515-LT-59 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 29891-LT-59, 
28430-LT-59, 27659-LT-59, and 29515-LT-59 billed for date of service May 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 27, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab services. You say that you must see all patients in the nursing home that need 
care and have no option to determine which patients to perform services on. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab services provided on June 27, 2022, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for automatic external defibrillator provided 
on June 16, 2022, to July 16, 2022. 
 
You asked the Plan to waive the coinsurance for automatic external defibrillator. You say that you are 
disputing the share cost. 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 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for each automatic external defibrillator. This item/service falls 
within the durable medical equipment and related supplies benefit category. 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 coinsurance for automatic external defibrillator provided on June 16, 2022, to July 16, 2022.
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 LTACH is the enrollee's best chance 
for a quicker recovery and a more favorable outcome. The Plan denied your request. The Plan says the LTACH 
is not medically necessary, and the enrollee's needs can be met at a lower level of care such as an acute 
rehabilitation, skilled nursing facility, nursing facility, outpatient setting, or home care. 
 
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 where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  
 
 
 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: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a capsule endoscopy. You say that you think it is imperative for this 
procedure to be approved so it can be investigated why the enrollee is still losing blood. The Plan denied your 
request. The Plan says that the documentation submitted does not support the requirements for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 a capsule endoscopy. Our reviewer says 
that the capsule endoscopy considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has symptomatic anemia with demonstrated iron deficiency, and their provider is concerned 
for occult gastrointestinal blood loss. No source was identified by esophagogastroduodenoscopy or 
colonoscopy performed within the last few months. Our reviewer also found that the appropriate evaluation 
that is medically appropriate and necessary as the next step is the wireless capsule endoscopy as requested. 
 
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 capsule endoscopy have been met. Therefore, we decided that the Plan has to 
pre-approve a capsule endoscopy (91110).  
 
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: Favorable

 
We decided that the Plan has 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 needs to optimize level of function prior 
to returning home. The Plan denied your request. The Plan says that based on Medicare guidelines, the 
requested IRF services 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation shows that the enrollee has complex functional impairments (hip fracture 
is IRF compliant). Clinical documentation shows that the enrollee's active medical comorbidities and ongoing 
medical issues (labile blood pressure, pulmonary edema/congestive heart failure) thus the enrollee would be 
expected to require ongoing inpatient hospitalization with an interdisciplinary team approach to rehabilitation 
care. Evaluating physical and occupational therapy teams both recommend inpatient rehabilitation thus IRF 
criteria met. 
 
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 inpatient rehabilitation facility (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 lab services provided on September 27, 2021. 
 
You asked the Plan to pay for the lab services. You say that medical records were provided. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 the lab services provided on September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stationary compressed gaseous oxygen system 
(E0424). 
 
 
 You asked the Plan to pre-approve a stationary compressed gaseous oxygen system. You say that you currently 
have portable oxygen and a concentrator. The requested device was requested by your physician for 
preventative and/or precautionary purposes. The current tank only lasts 3 days and you have been without 
electricity service for 3 days. The Plan denied your request. The Plan says the Medicare policy does not cover 
additional or emergency oxygen systems because it is not considered a medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that emergency or stand-by oxygen systems for 
beneficiaries who are not regularly using oxygen will be denied as not reasonable and necessary since they are 
precautionary and not therapeutic in nature. 
 
We looked at the file and Medicare rules. The records show you currently have portable oxygen and a 
concentrator. Medicare rules confirm that an emergency system is not covered. Based on this information, we 
decided that Medicare rules for coverage of a stationary compressed gaseous oxygen system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a stationary compressed gaseous oxygen 
system (E0424).