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

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 11, 
2022. 
 
You asked the Plan to pay for procedure code 76641. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 11, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you were admitted for pelvic fractures after a fall. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is in need of a home ventilator 
used with noninvasive interface for pulmonary hypertension, pulmonary fibrosis, shortness of breath and 
general health. Medical records attached to prove medical necessity. The Plan denied your request. The Plan 
says the requested device will not be used exclusively in CPAP or bi-level PAP mode; therefore, the request is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and 
pulmonary fibrosis. Results of ABG done during recent hospitalization suggest it was actually a venous gas, 
but CO2 was normal, so the enrollee does not meet criteria for ventilatory assistance during sleep. The 
Life2000 system is not a true ventilator because it is not capable of providing full ventilatory support. It is 
designed primarily for use during activity. There is insufficient evidence of benefit in the treatment of COPD or 
interstitial lung disease. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from  
December 17, 2021, to December 20, 2021 with the reported secondary diagnosis G93.41, metabolic 
encephalopathy with DRG 637 originally billed. You asked the Plan to pay for the inpatient hospital services with DRG 637 originally billed. You say that the 
inpatient hospital services with DRG 637 originally billed is supported by the medical records. The Plan denied 
your request. The Plan says the inpatient hospital services with DRG 637 originally billed is not supported by 
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 secondary diagnosis G93.41, metabolic 
encephalopathy. 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 with DRG 637 originally billed. Our reviewer says that the documentation does not support that the 
inpatient care is payable as billed. Our physician reviewer found that in this case, there was no clinical or 
laboratory evidence of metabolic encephalopathy. The review has determined that the secondary diagnosis 
G93.41, metabolic encephalopathy, is not supported by the medical records.. 
 
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 December 17, 2021, to December 20, 2021 with the reported 
secondary diagnosis G93.41, metabolic encephalopathy with DRG 637 originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88361, 88312, 88305, and 88104 billed for 
date of service July 27, 2021. 
 
You asked the Plan to pay for procedure code(s) 88361, 88312, 88305, and 88104. You say that this testing is 
the standard of care and should be covered. The Plan denied your request. The Plan says these codes are included in the facility payment and are not separately payable. You did not bill with the 26 modifier as is 
required. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88361, 88312, 88305, 
and 88104. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88361, 
88312, 88305, and 88104. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 88361, 88312, 88305, and 88104 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code(s) 88361, 88312, 88305, and 88104 billed for date of service July 27, 2021.
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 
December 24, 2021, to December 28, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. 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 871. 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 
the enrollee presented with a GCS of 12 with SOFA of 2. However, there was also conflicting information in 
the documentation such as another GCS of 15 with no confusion noted and alert and oriented x 3. Vitals were 
stable, lactate A was not elevated, normal bilirubin, normal platelet count, normal creatinine, and appeared to 
be responding to initial care. This describes a patient without sepsis based on the Sepsis 3 criteria. Therefore, 
the records do not support the use of principal diagnosis code A41.9 (sepsis, unspecified organism) 
or secondary diagnosis code R65.20 (severe sepsis without septic shock) in this case, with lack of support 
for DRG 871 as a result.   
 
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 December 24, 2021, to December 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Inpatient hospital services provided on 
August 17, 2022, to August 30, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you were expecting a 
bill of $120.00. 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 $300 
copayment per day for days 1 to 5 for inpatient hospital care. You are only responsible for $455.50 because you 
have reached your maximum out-of-pocket. 
 
You have been asked to pay $300 copayment per day for days 1 to 5 for inpatient hospital services. This 
item/service falls within the inpatient hospital care 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 Inpatient hospital services provided on August 17, 2022, to August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for continuous airway device and humidifier 
heated used with pap provided on July 11, 2022, to August 11, 2022. 
 
You asked the Plan to waive the coinsurance for continuous airway device and humidifier heated used with 
pap. You say that you are disputing the share cost. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies. The allowed amounts of these durable medical 
equipment total $357, resulting in a total coinsurance amount of $71.40. 
 
You have been asked to pay 20% coinsurance for continuous airway device and humidifier heated used with 
pap. This item/service falls within the durable medical equipment and related supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for continuous airway device and humidifier heated used with 
pap provided on July 11, 2022, to August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that if the enrollee gets off the ventilator, she 
can go backward health wise. The Plan denied your request. The Plan says the records do not show FEV1/FVC 
greater than or equal to 70% and a sleep study with an increase in the enrollee's carbon dioxide levels by at 
least 7 mm Hg; or that the requested device will not be used exclusively in CPAP or bi-level PAP mode. The 
request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe obesity, 
obesity-hypoventilation syndrome, OSA, and pulmonary hypertension. The enrollee does not have COPD, 
thoracic restrictive disease, or neuromuscular disease. During recent hospitalization VBGs suggested possible 
CO2 retention, but chronic CO2 retention is not confirmed with ABG done while stable. If the enrollee does 
have chronic CO2 retention, she may benefit from BiPAP during sleep. Medicare does not cover a home 
ventilator when used as BiPAP, or in the treatment of OHS. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 93882 billed for date of service July 30, 
2022. 
 You asked the Plan to pay for procedure code(s) 93882. You say that you would like the Plan to reconsider by 
reviewing the medical records. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable. You did not bill with the required 26 modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 93882. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 93882. Based on this information, 
we decided that Medicare rules for coverage of procedure code 93882 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 93882 billed for date of service July 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes 
provided to the enrollee on March 8, 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 the records do not support the services billed. 
 
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 asked our coder 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 reviewer found that hospital discharge day 
management: more than 30 minutes (CPT 99239) was requested. However, within the provided documentation 
available for review, there was no hospital discharge day management note with a documented duration of 
more than 30 minutes as required to justify this code.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital discharge day management; more than 30 minutes provided to the enrollee on March 8, 
2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the services (76642) provided on August 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the MUE value 
has been exceeded. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the MUE value for code 76642 is 1, and has been exceeded 
as 2 units were billed. However, a CPT code search shows that the MUE value for code 76642 is 2. As such, it 
is appropriate to bill 2 units of code 76642. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the services (76642) provided on August 22, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 28122) provided to the 
enrollee on January 29, 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 Current Procedural Terminology (CPT) code 28122-59 RT (1 Unit) remains not supported. This 
code is included in Current Procedural Terminology (CPT) 28820; therefore, it cannot be separately 
reimbursed. 
 
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 28122 is "Partial excision (craterization, saucerization, 
sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); tarsal or metatarsal bone, except talus 
or calcaneus." 
 
We asked our coder 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 reviewer found that the operative report documents "Partial fifth metatarsal resection completed to aid in closure." The operative report describes partial excision 
was performed to aid in closure, and in this case would be included in the primary procedure toe amputation, as 
closures are integral part of the primary procedure. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure code 28122) provided to the enrollee on January 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 10061 for services provided on June 23, 2022. 
 
You asked the Plan to pay for code 10061. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 10061. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for code 
10061 have not been met. Therefore, we decided that the Plan does not have to pay for code 10061 for services 
provided on June 23, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from June 14, 2022, to 
June 22, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that the services should be covered. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit at the time they were admitted for inpatient hospital care 
at issue in this case. Though the record shows that the enrollee revoked their hospice benefit on June 14, 2022, 
Original Medicare is responsible for payment for services until the first day of the month after the hospice 
election has been revoked or terminated. Therefore, we decided that the Plan does not have to pay for the 
inpatient hospital care provided from June 14, 2022, to June 22, 2022.