Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cystoscopy removal of clots (52001) provided on July 26, 
2022. 
 
You asked the Plan to pay for the cystoscopy removal of clots (52001). You say that the primary surgeon 
requested this provider to assist due to being medically necessary. You say that the medical records support the 
need for an assistant surgeon and the claim should be paid. The Plan denied your request. The Plan says an 
assistant at surgery may not be paid for this procedure. 
 
  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 52001. 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 the 
cystoscopy removal of clots (52001) have not been met. Therefore, we decided that the Plan does not have to 
pay for the cystoscopy removal of clots (52001) provided on July 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 6, 2022, 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 the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code 
 
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 principal diagnosis code A41.9, described as sepsis, 
unspecified organism. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the enrollee is a 72-year-old male who presented 
with a one-day complaint of abdominal pain in the suprapubic area. Computed tomography (CT) 
abdomen/pelvis positive for acute appendicitis. Enrollee was admitted and had a laparoscopic appendectomy 
on March 7, 2022. Following surgery, the patient developed a paralytic ileus requiring placement of a 
nasogastristic (NG) tube which extended his length of stay. Our physician reviewer found documentation does 
not support the billed code.  
 
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 March 6, 2022, at the Diagnosis Related Group (DRG) originally 
billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service November 
11, 2022. 
 
You asked the Plan to pay for procedure code A0425. You say that this service was medically necessary and is 
supported as billed. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed per line. 
 
The Plan must follow Medicare rules. Medicare rules say that for codes with an MAI of 1, each line of a claim 
with that HCPCS/CPT code will be separately adjudicated against the MUE value for that code. A single line 
may not exceed the MUE for that code, but additional lines for additional units may be reported with an appropriate modifier.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1, meaning that no more 
than 250 units may be billed per line. You billed 264 units of this code on a single line, exceeding the MUE. 
Based on this information, we decided that Medicare rules for coverage of procedure code A0425 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code A0425 billed for date of 
service November 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport coded 
A0998 provided on August 16, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment, no transport. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 16, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport coded A0998 provided on August 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical records. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210 x14), surgical removal of 
tooth roots (D7250 x6) and alveoloplasty (D7310 x6). 
 
You asked the Plan to pre-approve the dental services. You say that you are in need of having your teeth pulled 
due to your health. You say you are in pain and need your teeth removed as soon as possible. The Plan denied 
your request. The Plan says the request for additional surgical extractions (D7210) is denied as the benefit has 
been exceeded. The Plan also says surgical removal of tooth roots (D7250) and alveoloplasty (D7310) are 
denied as non-covered codes. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical extractions (D7210 x14), surgical removal of tooth roots (D7250 x6) and alveoloplasty (D7310 x6).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Premarin cream. 
 
You asked the Plan to pre-approve Premarin. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Premarin 
cream.  
 Benefits for Premarin may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on August 18, 
2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the items rendered are not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the proof of delivery did not include an order number or details to corroborate the delivery ticket 
submitted. In addition, the proof of delivery was not itemized to indicate the specific supplies. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success.  Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies provided on 
August 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on September 8, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for x-rays. You say that you disagree with this denial. The Plan denied your request. 
The Plan says these services have been correctly denied. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for x-rays provided on September 8, 2022, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the monthly supply allowance for a continuous glucose monitor (CGM) 
billed for date of service September 14, 2022. 
 
You asked the Plan to pay for the CGM supply allowance. You say that this claim should be paid because the 
necessary supplies were delivered. The Plan denied your request. The Plan says that the medical records 
included the proof of delivery, however, the date of service of September 14, 2022, does not match the 
delivery/shipping date or the date the label was created. 
 
The Plan must follow Medicare rules. Medicare rules say that a supplier may bill monthly (every 30 days) for 
the K0553 supply allowance as long as the amount of supplies needed to last 30 days after the DOS have been 
provided prior to the DOS.   
 
We looked at the file and Medicare rules. For CGM supply allowance payment, the DOS is always 30 days 
after the prior months date of service. Though generally the DOS is required to match the shipping date or 
delivery date, CGM supply allowances may be billed on a monthly basis even if the supplies necessary for the 
30 days after the DOS have been delivered. The file shows that one month's worth of supplies was shipped on 
September 7, 2022, and was received by the enrollee on September 12, 2022. This means that the 30-day 
supply for the 30 days beyond September 14, 2022, were provided prior to the DOS. As such, the billing of the 
monthly allowance with DOS September 14, 2022, is appropriate. Based on this information, we decided that 
Medicare rules for coverage of the CGM supply allowance have not been met. Therefore, we decided that the 
Plan has to pay for the monthly supply allowance for a continuous glucose monitor (CGM) billed for date of 
service September 14, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for September 22, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the file 
shows that the services were not performed for a hospital inpatient. Therefore, we decided that the Plan does 
not have to pay for procedure code 85060 billed for September 22, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for continuous intraoperative neurophysiology monitoring (G0453) 
provided on September 8, 2022. 
 
You asked the Plan to pay for the neurophysiology monitoring. You say that the services should be covered as 
the enrollee disagrees with the denial and they are medically necessary. The Plan denied your request. The Plan 
says that the services denied correctly as they are considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the neurophysiology monitoring. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that the intraoperative neurophysiology monitoring is recommended for 
enrollees who are at increased risk for neurological injury during spinal procedures, including anterior cervical 
spinal fusion. 
 
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 neurophysiology monitoring have been met. Therefore, we decided that the 
Plan has to pay for continuous intraoperative neurophysiology monitoring (G0453) provided on September 8, 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the appropriate level of care 
for the enrollee. The Plan denied your request. The Plan says criteria for admission to the LTACH have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care at the present acute care hospital. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PVA at additional levels T11, L1, L2, L4) (22515 and 
22514). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not 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 the services. Our physician reviewer 
found there is no imaging evidence that the additional fractures in T11, L1, 2 and 4 are less than six (6) weeks 
old. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PVA at additional levels T11, L1, L2, L4) (22515 and 22514).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93005 provided on September 21, 2022. 
 
You asked the Plan to pay for code 93005. 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 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 93005 is electrocardiogram, routine ECG with at least 12 
leads; tracing only, without interpretation and report. 
 
We find that CPT code 93005 is not supported in the medical record. Specifically, code 99285 was billed on 
the same date of service with a revenue code of 450. Code 99285 has a status indicator of "V". Code 93005 has 
a status indicator of Q1, which makes code 93005 not separately payable. Based on this information, we 
decided that Medicare rules for coverage of code 93005 have not been met. Therefore, we decided that the Plan 
does not have to pay for code 93005 provided on September 21, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing of up to 7 drug classes (G0480) provided on 
June 16, 2021. 
 
You asked the Plan to pay for definitive drug testing. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met because the 
services at issue were reported with an incorrect POS code. 
 
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. Specifically, the Plan's denial states that the laboratory services at issue have 
been billed with the incorrect POS code. The case record does not include medical records to support the Plan's 
assertion that the laboratory specimen was collected in an outpatient office setting. It is the Plan's responsibility 
to support its denial with evidence. In this case, the Plan's denial has not been supported, so we must find in 
your favor. Therefore, we decided that the Plan has to pay for definitive drug testing of up to 7 drug classes 
(G0480) provided on June 16, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic profiling on oncology biopsy of ovarian lesions 
(81503) provided on October 4, 2022. 
 
You asked the Plan to pay for genetic profiling services. You say that these services were reasonable and 
necessary. The Plan denied your request. The Plan says the diagnosis codes submitted on this claim are 
incompatible with one another. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that diagnosis codes for unspecified side should rarely be used, such as when the documentation in 
the record is insufficient to determine the affected side and it is not possible to obtain clarification. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic profiling services have not been met. Specifically, the record shows that diagnosis codes 
N83.202 (unspecified ovarian cyst, left side) and N83.209 (unspecified ovarian cyst, unspecified side) were 
reported on this claim. It is inappropriate to use a diagnosis code that reports an unspecified side when a side 
has been specified. In this case, the left side is specified. Therefore, we decided that the Plan does not have to 
pay for genetic profiling on oncology biopsy of ovarian lesions (81503) provided on October 4, 2022.