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

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 3, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service August 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS), 
four lead. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of enrollment in a clinical study. 
 
The rules say that a TENS unit is only covered for chronic low back pain when the patient is enrolled in an 
approved clinical study meeting all of the requirements. 
 
The record does not show any evidence of enrollment in a covered clinical study. Based on this information, 
we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS), four lead.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the cervical spine with contrast material 
(72126). 
 
You asked the Plan to pre-approve a cervical-spine CT scan. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 cervical-spine CT scan. Our reviewer 
says that the requested service is not medically reasonable and necessary in this case. Our physician reviewer 
found the available records contain a reference to ordering a magnetic resonance imaging (MRI) of the cervical 
spine. The enrollee has no history of documented contraindication to MRI such as pacemaker or other battery-
operated medical device. In addition, as there is no neurological deficit or red flag, there is no mention of 
conservative management such as a 6-week trial of physical therapy. No plain X-rays of the cervical spine are 
noted in the submitted material. 
 
 
  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 cervical-spine CT scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the cervical spine with contrast material (72126).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service May 2, 2022. 
 
You asked the Plan to pay for procedure code 64447. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.   
In this case, the MUE for CPT code 64447 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 64447 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 64447 billed for date of service May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Alpha-Stim device received on July 29, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary for your condition. The 
Plan denied your request. The Plan says services that are not medically necessary are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a written order/prescription is a written 
communication from a treating practitioner that documents the need for a beneficiary to be provided an item of 
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).  
 
There is no evidence that this device was ordered by the treating physician. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for an Alpha-Stim device received on July 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional pair of eyeglasses purchased on August 26, 
2022. 
 
You asked the Plan to pay for the additional pair of eyeglasses. You say that you have a vision benefit of $200, 
and you should be reimbursed because you were misinformed. The Plan denied your request. The Plan says 
your supplemental vision benefit gives you up to $200 per year for a single pair of glasses with standard lenses. 
The Plan also says the payment of the second pair of glasses and lenses is denied. 
 
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 up to 1 pair of glasses or 1 pair of contact lenses every year. 
 
We looked at the file and the Plan's rules. The record shows that the Plan agreed to pay for one pair of glasses 
in full, and your glasses benefit has been exhausted. Based on this information, we decided that the Plan's rules 
for coverage of the additional pair of eyeglasses have not been met. Therefore, we decided that the Plan does 
not have to pay for the additional pair of eyeglasses purchased on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic images (D0330) provided on 
October 3, 2022. 
 
You asked the Plan to pay for the dental service. You say that you did not know about the limitations of the x-
rays. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of November 20, 
2021. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic images (D0330) 
provided on October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable. 
  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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on September 30, 2022. 
 
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. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 pay for the anesthesia services 
rendered on September 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found this is an elective procedure that the enrollee will be medically cleared for prior to the procedure. There is no documentation from the enrollee's internist /liver specialist documenting a 
concern related to post-operative management for the enrollee's "liver failure. There is no documentation 
provided to support the expectation the enrollee will require a greater than 2 midnight stay based on medical 
needs. 
 
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 pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99214 provided on August 15, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are not separately payable. 
 
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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, payment for the surgery 
includes the benefit for pre-operative, post-operative, and same day visits. It also includes the benefit for 
related procedures and services. This means this service is not separately payable as billed. Based on this 
information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we 
decided that the Plan does not have to pay for the office visit coded 99214 provided on August 15, 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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at the current skilled nursing facility where 
enrollee is currently residing. 
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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 laboratory services provided to the enrollee on July 19, 2022. 
 
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 Medicare does not cover services that are not performed by a Medicare-certified provider. 
 
Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. 
 
The rendering provider is not eligible to bill Medicare. The plan did not pre-approve the services. We found no 
exception that would require the plan to pay for these items/services. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services provided to the enrollee on July 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
March 13, 2021, to March 17, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
medically necessary. The Plan denied your request. The Plan says the DRG was updated.  
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 637. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the physician noted metabolic encephalopathy secondary to hypoglycemia, seizure, and viral encephalitis. 
The patient's electroencephalography demonstrated diffuse encephalopathy. The review has determined that the 
documentation did not support diagnosis code G93.41 - metabolic encephalopathy. The records support DRG 
639 in this case.  
 
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 from March 13, 2021, to March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, ultra-light 
material (titanium, carbon fiber or equal) (L5940). 
 
You asked the Plan to pre-approve a prosthetic. You say that the requested prosthetic is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the request for L5940 exceeds the enrollee's need and 
does not meet the Medicare criteria of reasonable and 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 prosthetic. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found according to Medicare, additional features or components to a prosthesis may be necessary 
depending on the enrollees potential functional abilities. Potential functional ability is based on the reasonable 
expectations of the prosthetist, and treating practitioner, considering multiple factors. These factors include the 
enrollees past history, current condition including the status of the residual limb and the nature of the other 
medical problems and the enrollees desire to ambulate. In this case, the documentation indicates the enrollee 
has had a partial foot amputation. The requested device is indicated for a below-the-knee amputation, which 
exceeds the needs of the enrollee. 
 
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 prosthetic have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or 
equal) (L5940).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for provided on October 6, 2022. 
 
You asked the Plan to pay for the limited oral evaluation (D0140). You say that the benefit listed is unclear and 
the occlusal adjustment should be covered. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 18, 2022. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on 
October 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Inogen G5 portable oxygen concentrator provided to the 
enrollee on May 12, 2022. 
 
You asked the Plan to pay for the item. You say that you were advised that this would be covered. The Plan 
denied your request. The Plan says there is no documentation of lower oxygen levels or the physician stating a 
need for home oxygen. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 item Our reviewer says that the 
requested concentrator is not medically reasonable or necessary. Our physician reviewer found that the 
provided medical records document a diagnosis of chronic obstructive pulmonary disease and one office pulse 
oximetry reading of 89% on 11/11/2021 at 1101; two minutes later (with no reported treatment) his reading 
was 94%. A more recent visit not of 06/01/2022 reported an oximetry reading of 94%. Records do not 
document an oximetry reading of 88% or less or any dependent edema suggesting congestive heart failure; or 
pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated 
blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, 
III, or AVF); or, erythrocythemia with a hematocrit greater than 56% as required. There is no documentation 
that supplemental oxygen is still medically necessary and reasonable. The provided records do not document 
any statement from the patient's treating physician that supplemental oxygen 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 item have not been met. Therefore, we decided that the Plan does not have 
to pay for the Inogen G5 portable oxygen concentrator provided to the enrollee on May 12, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care services provided from June 12, 2022, to 
June 27, 2022. 
 
You asked the Plan to pay for home health care services. You say that a notice of authorization is on file for the 
denied claim. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 8, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for home health care services 
provided from June 12, 2022, to June 27, 2022.