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

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on 
January 20, 2022. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the recoupment. 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for each Medicare-covered outpatient surgery at an out-of-network hospital 
outpatient facility or ambulatory surgical center.  
 
Review of the file shows that the enrollee had outpatient surgical services from an out-of-network provider on January 20, 2022. The enrollee has been asked to pay a $250 copayment for these services. This item/service 
falls within the Medicare-covered outpatient surgery at an out-of-network hospital outpatient facility or 
ambulatory surgical center benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the outpatient surgical services rendered on January 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service July 7, 2021. 
 
You asked the Plan to pay for procedure code 77062. 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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the synthetic sheepskin pad provided on June 16, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the information 
received does not support coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that mattress overlays are only covered under certain 
medical indications.  
 
We looked at the file and Medicare rules. The records do not show that the enrollee is immobile, cannot make 
significant body position changes, or has pressure ulcers. 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 synthetic sheepskin pad provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 28, 2022, billed 
with code 0037U. 
 
You asked the Plan to pay for the genetic testing. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says the unique identifier was not reported on the claim as required. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. The identifier must be reported on the claim for 
the testing. 
 
We looked at the file and Medicare rules. The claim does not include the required identifier. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the genetic testing provided on February 28, 2022, billed with 
code 0037U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric stimulation therapy (97014) provided on May 10, 
2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under your 
contractual policy or by Medicare. 
 
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 electric stimulation therapy (97014) provided on May 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from admission to an LTACH to regain their prior level of functioning. The Plan denied your request. The Plan says admission to the LTACH is not medically necessary and the enrollee is receiving the proper care in their current acute care hospital.

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 that the enrollee appears to be improving but still somewhat unstable and should only require short-term additional acute care hospital services that can be safely administered at the current facility until more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is still unstable and as it would not be clinically advantageous at this time. 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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services (99232, 99223) provided from August 7, 
2021, to August 20, 2021. 
 
You asked the Plan to pay for inpatient services. You say that this claim is not a duplicate, and you require 
payment or proof of previous 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 September 1, 2021. 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 dates. 
Based on this information, we decided that the Medicare rules for inpatient services have not been met. 
Therefore, we decided that the Plan does not have to pay for inpatient services (99232, 99223) provided from 
August 7, 2021, to August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally 
or extra-orally (D0350) and the scaling in presence of generalized moderate or severe gingival inflammation
full mouth, after oral evaluation (D4346) provided on June 14, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial 
photographic image obtained intra-orally or extra-orally (D0350) and the scaling in presence of generalized 
moderate or severe gingival inflammationfull mouth, after oral evaluation (D4346) provided on June 14, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74430 billed for date of service December 
30, 2021. 
 
You asked the Plan to pay for procedure code 74430. You say that these services were coded correctly. The 
Plan denied your request. The Plan says the payment for code 74430 is bundled into the payment for code 
74420. 
 
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 74430 
is a column II code to column I code 74420 with a modifier indicator of 0. The column II code is therefore not payable. 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 74430 billed for date of service December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 1, 2022, billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81328, 81335, 81355, 
81407, 81479. 
 
You asked the Plan to pay for the genetic testing. The Plan denied your request. The Plan says a panel should 
be billed using one Current Procedural Terminology (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 have 
not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 1, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81238, 81291, 
81306, 81328, 81335, 81355, 81407, 81479.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from September 27, 
2021, to September 30, 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 this 
claim should be paid at the DRG originally billed. The Plan denied your request. The Plan says the principal 
diagnosis of A41.1 (sepsis due to other specified staphylococcus) is not supported in the medical records. 
 
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 the principal diagnosis of A41.1 (sepsis due to other 
specified staphylococcus). 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 principal diagnosis of A41.1 (sepsis 
due to other specified staphylococcus) is not supported in the medical record. Our physician reviewer found per 
the emergency department medical decision making note the patient was concerning for urinary tract infection 
(UTI), pyelonephritis and urosepsis, but his vitals are otherwise stable. The patient was tachycardic, however, 
per the emergency department physician the patient was in atrial flutter with rapid ventricular rate. The patient's 
respirations and oxygen saturation were within normal limits. The patient is on chronic anticoagulation for 
atrial flutter; however, he had no evidence of acute blood loss, and his platelets were within normal limits. The 
patient was found to have marginal hepatic steatosis appearance with trace gallbladder sludge on imaging, and 
other lab values were also found to be within normal limits. The patient was not found to be hypotensive and 
never required vasopressors. The patient was alert and oriented to person, place, time, and situation; their 
Glasgow Coma Score (GCS) was noted to be 15. The patient's creatinine was measured up to 1.34 however, 
this appears to be within normal limits for this laboratory running the test, and the patient's baseline is noted to 
be up to 1.4.  
 
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 from September 27, 2021, to September 30, 2021, 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 segmental 
pneumatic appliances (E0667, E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you have had 
multiple vein surgeries that did not work, and this machine is the only thing that helps you with your leg 
swelling. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an 
advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of 
either E0650 or E0651. 
 
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 segmental pneumatic appliances (E0667, E0656).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group 
(DRG) 292 provided from April 26, 2021, to May 1, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the 
billing of secondary diagnosis codes E87.0 and J44.0 with DRG 292. The Plan denied your request. The Plan 
says the medical records do not support the billing of secondary diagnosis codes E87.0 and J44.0 with DRG 
292. 
 
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 secondary diagnosis codes E87.0 and J44.0. 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. Our reviewer 
says that the medical records do not support the billing of secondary diagnosis codes E87.0 and J44.0 with 
DRG 292. Our physician reviewer found documentation supported an admission for congestive heart failure 
(CHF) exacerbation. The enrollee presented with a sodium of 147, subsequent sodium levels were 145, 144 and 
142 respectively. "Mild hypernatremia" populated the problem list. Although the diagnosis of hypernatremia 
populated the problem list, the medical record does not specify a reason or suspected cause for the 
hypernatremia nor is there documentation of specific intervention to address/correct the hypernatremia. As 
noted above, although hypernatremia populated the problem list reasonable support within the health record 
must be present for this diagnosis. Regarding J44.0, the facility reported chronic obstructive pulmonary disease 
with (acute) lower respiratory infection, however; evidence of a lower respiratory infection could not be found. 
The review has determined that the medical records did not support the billing of secondary diagnosis codes 
E87.0 and J44.0 with DRG 292.  
 
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 with diagnosis related group (DRG) 292 provided from April 26, 2021, to 
May 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from November 6, 
2021, to November 12, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient services at the DRG originally billed. You say that this claim should 
be paid at the DRG originally billed. The Plan denied your request. The Plan says the principal diagnosis of 
A41.9 (sepsis, unspecified organism) is not supported in the medical record. The clinical findings in the record 
do not sufficiently support the diagnosis of sepsis based on Sepsis 3 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 the principal diagnosis of A41.9 (sepsis, unspecified 
organism). 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 services at the DRG 
originally billed. Our reviewer says that the principal diagnosis of A41.9 (sepsis, unspecified organism) is not 
supported in the medical record. Our physician reviewer found the patient was a then, 78-year-old male with a 
past medical history of gastric cancer who presented with syncope, generalized weakness, nausea, and 
decreased appetite. H & P exam documented vital signs of temp 101.2F, pulse 100, respiratory rate 18, blood 
pressure 129/65 and pulse oxygen saturation (SpO2) 95% on room air. The patient was described as in no acute 
distress, normal pulmonary effort, lungs revealed bibasilar crackles, and no focal neurologic deficits. 
Laboratory test results included a white blood cell count of 9.8K, platelet count 266K, blood urea nitrogen of 
12, creatinine 0.7, total bilirubin 1.8, and lactic acid 1.0. The patient's chest imaging showed right lower lobe 
consolidation. The patient was diagnosed with pneumonia and admitted for further care. Treatment included IV 
fluids and IV antibiotics. While it was acknowledged that the records include a physician-documented 
diagnosis of sepsis, and that Systemic Inflammatory Response Syndrome (SIRS) signs were present along with 
an elevated lactic acid, the clinical findings in the record did not sufficiently support the diagnosis of sepsis 
based on Sepsis 3 criteria.  
 
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 6, 2021, to November 12, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64408 billed for services provided on May 
16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code is separately reimbursable. The Plan 
denied your request. The Plan says modifiers are not allowed with this code pair. 
 
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 64408 is a column II code to column I code 69210 with a modifier 
indicator of 0. The column II code is therefore not payable. 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 64408 
billed for services provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate denture - maxillary (D5130), and unspecified 
removable prosthodontic procedure (D5899) provided on April 28, 2022. 
 
You asked the Plan to pay for an immediate denture - maxillary (D5130), and unspecified removable 
prosthodontic procedure (D5899). You say that there is no coverage for dentures and the policy covered 15 
percent of the cost for the work done. The Plan denied your request. The Plan says the dental services are not 
covered by your supplemental 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 pay for an 
immediate denture - maxillary (D5130), and unspecified removable prosthodontic procedure (D5899) provided 
on April 28, 2022.