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

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on 
January 7, 2020, to January 9, 2020. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the Payment Integrity post-service post-pay clinical validation audit shows that the provider has 
reported inpatient hospital services with the incorrect DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 640 (MISCELLANEOUS DISORDERS OF 
NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC). 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 services. Our reviewer says that the services at issue in this case 
were not supported by the medical records. Our physician reviewer found that the review found no evidence to 
support a significant improvement in mental status or change from baseline throughout the admission. The 
enrollee was diagnosed with failure to thrive and was discharged after a 2-day length of stay. DRG 640 is not 
appropriate. The appropriate DRG is DRG 641: MISCELLANEOUS DISORDERS OF NUTRITION, 
METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC.  
 
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 to the enrollee on January 7, 2020, to January 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) 
provided on November 17, 2020. 
 
You asked the Plan to pay for the non-emergency ambulance transportation. The Plan denied your request. The 
Plan says the request for non-emergent ambulance transportation is not medically necessary because the 
medical record documents that the enrollee is not bed bound and is able to transfer and ambulate with minimal 
assistance. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 non-emergency ambulance 
transportation. Our reviewer says that the elements of the coverage criteria are not satisfied. Our physician 
reviewer found that the enrollee was transported from an acute care facility to a skilled nursing facility after 
discharge for dyspnea on exertion. The record does not indicate that the enrollee required the expertise and 
capabilities of a fully equipped ambulance. Our reviewer found that the enrollee was transported via stretcher. 
Our physician reviewer also found that the record does not indicate that the enrollee's clinical condition was 
such that other methods of transport were contraindicated. 
 
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 non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) provided 
on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing rendered on September 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and 
should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing rendered on September 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head 
(70544) provided on October 13, 2021. 
 You asked the Plan to pay for the MRA services. You say that you would like this claim reprocessed based on 
the medical records. The Plan denied your request. The Plan says this claim has not been 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 70544 
is a column II code to column I code 70551. 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 the magnetic resonance angiography (MRA) of the head (70544) 
provided on October 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
procedure is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that the intraosseous ablation of the basivertebral nerve (Intracept procedure) was requested. 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 requested services. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to show its safety and 
efficacy. Therefore, the requested services are not considered medically reasonable or necessary. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON vision care. You say that these services are necessary. The Plan 
denied your request. The Plan says out-of-network services are covered only in certain limited circumstances. 
The necessary care can be performed by an in-network provider. 
 
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 
ophthalmology visits 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 drug testing rendered on July 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. 
 
 
  
 
 Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on October 7, 2021. 
 
You asked the Plan to pay for an eye refraction. You say that your eye refraction was done by an in-network 
provider. You do not understand why it is not covered under your medical plan. The Plan denied your request. 
The Plan says the eye refraction was performed as part of an eye exam for a medical diagnosis billed and it 
cannot be covered under supplemental vision benefits as a routine service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is performed as a routine screening by a participating 
provider. 
 
We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, 
and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage 
of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye 
refraction (92015) provided on October 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with battery. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 2 PWC is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation states the enrollee 
has a mobility deficit but the physician progress notes do not support that the mobility deficit impairs mobility-
related activities of daily living (MRADLs) in the home and this mobility limitation is not ameliorated by a 
walker, cane, manual wheelchair. The physician progress note does not reveal a detailed 
musculoskeletal/neuromuscular exam or gait evaluation. While the enrollee may have the cognition to safely 
operate the K0823 wheelchair the treating physician documentation does not reveal that this device is 
medically necessary and will significantly improve MRADL participation. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Group 2 power wheelchair (PWC) with battery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6534. 
 
You asked the Plan to pre-approve compression stockings. You say that the request is a necessity for your care. 
The Plan denied your request. The Plan says rules for coverage for compression stockings have not been met. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6534.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist office visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visits. You say that you have seen this provider before 
and would like to continue to see the same provider. The Plan denied your request. The Plan says a list of in-
network providers was given to the enrollee the provide the same quality of 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 
specialist office visits to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 21, 
2021, to May 27, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the inpatient care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the clinical presentation and workup revealing a low severity clinical 
picture without plans for surgery or signs of severe infection, it was expected that the hospital course would not 
likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from May 21, 2021, to May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 4, 2020. 
 
You asked the Plan to pay for the services provided. You say that the information is used to adjust medications 
and reevaluate the enrollee. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The records show that the specimen was obtained at a skilled nursing 
facility. The claim, however, lists a place of service as an office. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on August 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on October 28, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on October 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third level of radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve RFA. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because the Plan 
approved 2 levels and no more than 1 to 2 levels per spine region can be done per session. 
 
The Plan follows Medicare rules. Medicare rules state that one to two levels of facet joint intervention, either 
unilateral or bilateral, are allowed per session per spine region. 
 
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 RFA. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a third level of radiofrequency ablation (RFA). Our physician reviewer found the enrollee has chronic lumbar pain causing functional impairment, has failed conservative 
treatment, and the first medial branch blocks provided greater than 80% pain relief. However, this request is for 
a third level and Medicare coverage criteria have a limitation of no more than 1 to 2 levels, either unilateral or 
bilateral, per spine region. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a third level of radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra heavy-duty wheelchair (K0007). 
 
You asked the Plan to pre-approve an extra heavy-duty wheelchair. You say that this item is medically 
necessary. The Plan denied your request. The Plan says a back-up wheelchair is not medically necessary and 
will not be covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. This power wheelchair serves the same purpose as an extra 
heavy duty wheelchair. Therefore, we decided that the Plan does not have to pre-approve an extra heavy-duty 
wheelchair (K0007).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service rendered on April 26, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status 
indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for 
the special anesthesia service rendered on April 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray services provided on September 30, 2021. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says there is no documentation supporting an additional study. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We looked at the file and the rules. The file shows that 2 claims were billed for the same service, on the same 
date of service. The records show that the Plan previously paid for the service. There is no documentation to 
show that the provider at issue provided 2 separate tests on the same date. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the chest x-ray services provided on September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge day services provided on April 23, 2021. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was in need of care. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the records 
provided do not indicate the amount of time spent on discharge day management. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for the discharge day services provided on April 23, 2021.