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

 
We decided that the Plan does not have to pay for the refill kit for an implantable pump (A4220) provided 
March 23, 2022. 
 
You asked the Plan to pay for the implantable pump refill kit. You say that  The Plan denied your request. The 
Plan says procedure A4220, has a status indicator of 'P' on the CMS Physician Relative Value File, and is 
always bundled into payment for other services not specified and no separate payment is made per Medicare. 
 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 the 
refill kit is an add-on code and has not been billed with an appropriate primary procedure code. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the refill kit for an implantable pump (A4220) provided March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service May 16, 
2022. 
 
You asked the Plan to pay for procedure code 76642. 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 76642 is 2. The MAI value for this code is 2. You billed 4 units of this 
code, exceeding the MUE. 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 May 16, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation without medical services 
provided on May 28, 2021. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation without medical services. The Plan denied 
your request. The Plan says this provider type is not eligible in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program.  
 
 
  
 
Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation without 
medical services provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 21, 2022 billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81328, 81355, 0031U, 0032U, 0033U, 81407 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are requesting a re-determination of 
the denial and have enclosed documentation to substantiate the claim. The Plan denied your request. The Plan 
says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be 
considered part of the 
same panel. A panel constitutes a single procedural service, so one HCPCS code must be submitted for the 
panel. 
 
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 billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 21, 2022 billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81328, 81355, 0031U, 0032U, 
0033U, 81407 and 81238.
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. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an IRF. 
 
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 clinical documentation shows that even though the enrollee has new functional 
impairments, they are medically stable in the home setting. Our reviewer also found that the enrollee does not 
have active comorbidities requiring inpatient hospitalization, thus IRF criteria has not been met and are 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code  billed for date of service February 19, 2022. 
 
You asked the Plan to pay for procedure code . You say that you have provided medical records to support 
payment. 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 12001 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  have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code  billed for date of service February 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting inpatient rehabilitation services. 
The Plan denied your request. The Plan says your needs can be met at a lower level of care such as skilled 
nursing facility (SNF), home health or long-term care setting. 
 
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 are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the homemaker services (S5130) provided from March 2, 
2022, to March 5, 2022. 
 
You asked the Plan to pay for the homemaker services. The Plan denied your request. The Plan says 
homemaker services are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the homemaker services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the 
homemaker services (S5130) provided from March 2, 2022, to March 5, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient surgical procedure rendered on February 25, 2022, to 
February 27, 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 that procedure code 22846 is not listed as an "inpatient-only" procedure. 
 
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 states that billed procedure 22846 is not found on the inpatient only 
procedure list; however, this procedure is clearly listed on the 2022 Inpatient Only List for Medicare. The Plan 
has not provided any documentation to support that the services are not payable as billed. Therefore, we 
decided that the Plan has to pay for the inpatient surgical procedure rendered on February 25, 2022, to February 
27, 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 code 68801-59 billed for date of service July 28, 2021. 
 
You asked the Plan to pay for code 68801-59. You say that this service was billed correctly and should be paid. 
The Plan denied your request. The Plan says you have not supplied medical records to support the billing of 
this code. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of code 68801-59 billed for date of 
service July 28, 2021, have been met. In this case, medical records are required to determine if the billing of 
code 68801 with modifier 59 is appropriate for separate payment. The Plan requested medical records from you 
multiple times, but you have failed to respond.  Without these medical records, we cannot determine that the 
billing of modifier 59 (which would potentially allow for separate payment of this code) is appropriate. 
Therefore, we decided that the Plan does not have to pay for code 68801-59 billed for date of service July 28, 
2021.
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 would benefit from a short-term IRF 
stay. The Plan denied your request. The Plan says the request for IRF placement is not medically necessary. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and segmental 
gradient pressure pneumatic appliance (E0673) provided February 17, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that the DME 
equipment was prescribed by the doctor and was issued to the enrollee for use during their surgery. You are not 
contracted with the facility or the prescribing physician and do not receive payment from either provider. The 
Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent 
deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) and segmental gradient pressure pneumatic appliance 
(E0673) provided February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic casts (D0470) provided on February 28, 2022. 
 
You asked the Plan to pay for diagnostic casts. You say that these services were necessary as you could not eat 
with your previous denture, and you cannot afford this care without the help of insurance. The Plan denied your 
request. The Plan says this service is not covered by your dental benefit. 
 
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 diagnostic 
casts (D0470) provided on February 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nail debridement (11720) provided on March 14, 2022. 
 
You asked the Plan to pay for the nail debridement. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is 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. 
 
We find that CPT code 11720 is not supported in the medical record. Specifically, CPT code 11720 has a 
global surgery period of 0 days. Surgery code 11720 is included within the global surgery package of 
procedure 11750 billed on the same date of service. Based on this information, we decided that Medicare rules 
for coverage of the nail debridement have not been met. Therefore, we decided that the Plan does not have to 
pay for a nail debridement (11720) provided on March 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 8, 
2022. 
 You asked the Plan to pay for procedure code 70450. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service February 22, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service February 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-lab polysomnography (PSG) (95810). 
 
You asked the Plan to pre-approve an in-lab PSG. You say that an in-lab study is medically necessary for the 
enrollee due to recurrence of symptoms and choking during the night. The Plan denied your request. The Plan 
says this request does not meet medical necessity. 
 
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 an in-lab PSG. Our reviewer says that 
the requested in-lab PSG is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has a high suspicion for obstructive sleep apnea (OSA), based on the STOP-Bang 
assessment and the history of OSA. Therefore, a home PSG would be considered reasonable and necessary to 
confirm the diagnosis. Our reviewer also found that the enrollee does not have any issues that would require an 
attended PSG, such as severe heart or 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 an in-lab PSG have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an in-lab polysomnography (PSG) (95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need orthotics to alleviate foot pain. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this item is necessary for your condition. The 
Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies rendered on May 12, 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 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed supplies. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies 
rendered on May 12, 2022.