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

 
We decided that the Plan does not have to pre-approve a pylon shock reducing feature (L5988) and multiaxial 
ankle (L5968). 
 
You asked the Plan to pre-approve a pylon shock reducing feature and multiaxial ankle. You say that the items 
are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 pylon shock reducing feature and 
multiaxial ankle. Our reviewer says that the member does not need these items. Our physician reviewer found 
the enrollee is not an advanced ambulator and there is no evidence the advanced accessories are medically 
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 a pylon shock reducing feature and multiaxial ankle have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pylon shock reducing feature (L5988) and 
multiaxial ankle (L5968).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement in place between the dialysis facility and the laboratory regarding payment. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 11, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 2, 2021, to 
November 7, 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 these 
services and diagnoses were reported appropriately and are supported as billed. The Plan denied your request. 
The Plan says the DRG submitted on this claim is not supported in the medical record. 
 
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 sepsis, unspecified organism (A41.9). 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 this diagnosis is not supported in the medical record. Our physician reviewer found that 
the clinical documentation shows that the enrollee had signs of a urinary tract infection (UTI) upon arrival, 
hyperglycemia and elevated creatinine. Although the attending physician documents that the enrollee was, 
admitted for sepsis secondary to UTI, the admission information does not meet systemic inflammatory 
response syndrome (SIRS) criteria and the discharge summary refers to a clinical course without 
documentation of sepsis. There is evidence of other system dysfunction; however this is not documented as 
related to organ dysfunction thus clinical documentation does not support a diagnosis of sepsis, unspecified 
organism (A41.9).   
 
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 November 2, 2021, to November 7, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mental health services provided on August 
08, 2022, to August 29, 2022. 
 
You asked the Plan to waive the copayment for mental health services. You say that you should not have to pay 
this copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for partial hospitalization services. 
 
You have been asked to pay a $45 copayment for mental health services. This item/service falls within the 
partial hospitalization services 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 copayment for mental 
health services provided on August 08, 2022, to August 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service March 14, 
2022. 
 
You asked the Plan to pay for procedure code 95941. You say that you would like the Plan to reconsider their 
denial of payment. 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 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95941 billed for date of service March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service August 10, 
2022. 
 
You asked the Plan to pay for procedure code 85060. You say that this service was necessary and was billed 
appropriately. The Plan denied your request. The Plan says this service is not payable in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85060 have not been met. Specifically, the record shows that this service was 
furnished to an enrollee in an outpatient hospital (Place of Service code 22) setting. Therefore, we decided that 
the Plan does not have to pay for procedure code 85060 billed for date of service August 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on August 26, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the records show the services were medically 
necessary. The Plan denied your request. The Plan says utilization of network providers and authorization for 
certain services is required. 
 
 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the computed tomography (CT) scan provided on August 26, 2022, by an out-of-
network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit for the evaluation and 
management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive 
examination; and medical decision making of high level (code 99285) provided on August 17, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the correct code was billed. The 
Plan denied your request. The Plan says the criteria for code 99285 is not met as the presenting problem was 
not severe or an immediate significant threat to physiological function. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive 
examination; and medical decision making of high level. 
 
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 emergency department visit. Our 
reviewer says that says that the services at issue in this case were not supported by the medical records. Our 
reviewer found that the enrollee is a 75-year-old male with hypertension, pancreatitis and diabetes, who 
presented to the emergency department (ED) with headache and nausea and home systolic blood pressures 
around 200+. The enrollees blood pressure in the ED was 223/98. He was treated for hypertensive urgency 
with clonidine, ASA and blood pressure reduced to 138/73 and remained stable. Workup (labs, ECG, PE) was 
unremarkable. Due to the enrollees presentation being of low severity and low complexity with fairly quick 
response to simple antihypertensive medication administration, the CPT 99285 was not appropriate. CPT 
99284 would have been more appropriate for this care.   
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for an emergency department visit for the evaluation and management of a 
patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's 
clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical 
decision making of high level (CPT 99285) provided on August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the culture, fungi (mold or yeast) isolation, with 
presumptive identification of isolates (87101). 
 
You asked the Plan to pre-approve a mildew test. You say that you have been waiting for 5 months to do this 
test and you have very bad symptoms. The Plan denied your request. The Plan says the records received do not 
support that a test for mildew exposure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 mildew test. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee, with hypertension and hyperlipidemia presented for general cardiac follow-up 
with their treating physician. The enrollee denied any symptoms or changes in clinical status. A request for 
culture, fungi (mold or yeast) isolation, with presumptive identification of isolates (87101) was made with the 
enrollee reporting exposure to mildew and suspected toxic mold. No in-home test results were provided or 
described sample type from the enrollee intended to be cultured (skin, sputum, nasal, etc.). The treating 
physician did not document their intention to test and treat toxic mold exposure which is needed to support this request. Therefore, this request for fungi culture will be considered not medically 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 a mildew test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the culture, fungi (mold or yeast) isolation, with presumptive identification of isolates 
(87101).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel testing provided on July 22, 
2022. 
 
You asked the Plan to pay for the testing services. You say that the analysis supports optimal treatment 
planning. The Plan denied your request. The Plan says the testing does not meet the requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that infection disease pathogen testing is only 
covered under certain medical indications. 
 
We looked at the file and Medicare rules. The medical records show that the enrollee was being treated for a 
cough, present for 1 week. The records do not show that the enrollee was immune compromised. The testing of 
more than 6 pathogens was also not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the respiratory pathogen panel testing provided on July 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee should be admitted to an inpatient 
rehabilitation hospital for medically necessary care. The Plan denied your request. The Plan says the records do 
not show the need to take part in an intensive team for care, nor the need to be seen by a rehabilitation doctor at 
least three times a week for evaluation of functional and medical goals and progress. 
 
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 there is not a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 88120, 88112, 88313, and 
88312 provided August 9, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that as a national laboratory, you are a preferred 
laboratory for many physicians around the United States and it is the physician performing the procedure who 
makes the choice on sending their specimens to you for proper processing and diagnosis. The Plan denied your 
request. The Plan says this provider is not certified and/or eligible to be paid for this procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 88120, 
88112, 88313, and 88312 provided August 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Spinal Simplicity interspinous-interlaminar fusion 
device. 
 
You asked the Plan to pre-approve the Spinal Simplicity interspinous-interlaminar fusion device. You say that 
the enrollee has tried every amount of conservative treatment and his current diagnosis supports the medical 
necessity of the requested services. The Plan denied your request. The Plan says use of this device as a stand-
alone procedure has not been shown to be safe and effective in long term studies. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 Spinal Simplicity interspinous-
interlaminar fusion device. Our reviewer says that the Spinal Simplicity interspinous-interlaminar fusion device 
is not considered medically reasonable and necessary in this case. Our physician reviewer found the Spinal 
Simplicity interspinous-interlaminar fusion device is considered experimental. More research is needed. 
 
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 Spinal Simplicity interspinous-interlaminar fusion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Spinal Simplicity interspinous-
interlaminar fusion device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22845-80-59 and 50715-59-LT billed for 
date of service June 29, 2022. 
 You asked the Plan to pay for the billed services. 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. 
 
The CPT Code Manual definition of code 22845 is anterior instrumentation; 2 to 3 vertebral segments (List 
separately in addition to code for primary procedure). We find that CPT code 22845 is not supported by the 
medical records provided. 
 
The medical records do not show that code 50715, billed with the -59 modifier was a distinct procedural 
service from the primary procedure. Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 22845-80-59 
and 50715-59-LT billed for date of service June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 21, 2021, to July 
25, 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 these 
services and diagnoses were reported correctly and are supported as billed. The Plan denied your request. The 
Plan says the DRG submitted on this claim is not supported in the medical record. 
 
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 sepsis, unspecified organism (A41.9). 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 this diagnosis is not supported. Our physician reviewer found that the enrollee presented 
to the hospital with abdominal pain following endoscopic retrograde cholangiopancreatography (ERCP) the 
day prior. The enrollee had a fever, hypoxia requiring low dose oxygen support, tachycardia, and tachypnea. 
Treatment included fluids and antibiotics and the enrollee was diagnosed with pancreatitis. The enrollee had 
normal platelets, no hypotension, and a creatinine (Cr) level which decreased to 1.55 closer to baseline 
following fluids. The enrollees bilirubin elevation could be explained by the recent ERCP, there was no 
arterial blood gas results to confirm if it was less than 400, and the enrollee was not in acute distress and was 
alert and oriented. Due to the collective presentation not meeting Sepsis 3 criteria, without clear suggestion of 
organ dysfunction directly related to dysregulated response to infection, the diagnosis of sepsis is not 
appropriate for this admission.   
 
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 July 21, 2021, to July 25, 2021, at the Diagnosis Related Group 
(DRG) originally billed.