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

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service October 6, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the claim was billed properly and should be 
paid. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 
93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service October 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 CGM. The Plan denied your request. The Plan says a 
CGM is not covered under Medicare if the member is not on insulin. The Plan also says this enrollee has Type 
2 Diabetes Mellitus, which is controlled on Jardiance alone. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre 2 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle 
Libre 2 continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on October 6, 2021, to October 12, 2021, at the Diagnosis Related Group (DRG) originally billed.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this claim was correctly billed and should be paid. The Plan denied your request. The Plan says the DRG was reduced as diagnosis code G93.41 is not supported.

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 code G93.41, defined as 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 at the DRG originally billed. Our reviewer says that the documentation does not support the use of code G93.41. Our physician reviewer found it was acknowledged that the physician documented the enrollee was alert and oriented, somnolent, but following commands and answering questions appropriately and a diagnosis of metabolic encephalopathy due to hyperglycemia in multiple progress notes; however, there was no evidence that the somnolence improved with treatment of the hyperglycemia to support a change in mental status beyond baseline. The review has determined that the documentation did not support secondary diagnosis code G93.41, defined as metabolic encephalopathy.

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 October 6, 2021, to October 12, 2021, at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 15, 2021, billed 
with codes 95955, 95885, 95908, and 95927. 
 
You asked the Plan to pay for the medical services as billed. You say that this is billed correctly for medically 
necessary services. The Plan denied your request. The Plan says the codes at issue are not supported. 
 
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 95955 is electroencephalogram (EEG) during non-
intracranial surgery (eg, carotid surgery). The definition of code 95908 is nerve conduction studies; 3-4 studies. The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when 
performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in 
addition to code for primary procedure). The definition of code 95927 is short-latency somatosensory evoked 
potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous 
system; in the trunk or head. 
 
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 medical services as billed. Our reviewer says that the 
billed services are not supported by the medical records provided. Our reviewer found code 95955 is not 
supported as the procedure report does not include documentation of EEG during non-intracranial surgery (eg, 
carotid surgery).  Any additional EEG would be included in the primary procedure code for intraoperative 
EEG.  
 
For code 95908, the procedure report documents stimulation of pedicle screws via a monopolar handheld probe 
with incrementally increasing intensity until a threshold was found. The record does not include documentation 
of nerve conduction studies which measure amplitude and latency/velocity, and therefore, this procedure 
cannot be verified. Pedicle screw stimulation should not be reported with nerve conduction studies. Code 
95885 is defined as being done with nerve conduction studies. As the nerve conduction studies are not 
supported, this code also cannot be paid.  
 
For code 95927, the documentation does not support that the services described by this code were performed. 
 
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 medical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on January 15, 2021, billed with codes 95955, 
95885, 95908, and 95927.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service October 12, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that there is an authorization on file for these 
services. The Plan denied your request. The Plan says they have agreed to pay for the other therapeutic 
services; however, procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210) and the bone replacement graft ridge 
preservation (D7953) provided on November 9, 2022. 
 
You asked the Plan to pay for the extraction (D7210). You say that you are experiencing dental pain and your 
primary dentist refused to provide treatment. The Plan denied your request. The Plan says your benefit for the 
extraction (D7210) 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 November 9, 2022. The bone replacement graft ridge preservation (7953) not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the extraction (D7210) and the bone replacement graft ridge 
preservation (D7953) provided on November 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from August 12, 2022, to August 18, 
2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from August 12, 2022, to August 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87801, 87150 and 87324) provided on August 
19, 2022. 
 You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 (87801, 87150 and 87324) provided on August 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 so the 
enrollee can return safely to their prior level of function and/or maximum potential. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. Skilled 
therapies at home or at a skilled nursing facility may be approved upon request. 
 
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 the enrollee has 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a switch for lights and an expandable remote. 
 
You asked the Plan to pre-approve a switch for lights and an expandable remote. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested items are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a switch for lights and an expandable remote.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services on August 11, 2022, 
to September 6, 2022. 
 
You asked the Plan to pay for skilled nursing facility (SNF) services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the enrollee's benefit was exhausted 
by August 11, 2022, therefore services between August 11, 2022, and September 6, 2022, have been denied. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from May 1, 2022, 
and August 10, 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for skilled nursing facility (SNF) services on August 11, 2022, to September 
6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reline maxillary partial denture (D5760) and reline 
complete maxillary denture  (D5750). 
 
You asked the Plan to pre-approve the reline maxillary partial denture (D5760) and reline complete maxillary 
denture  (D5750). You say that you are appealing the denial for your denture repairs. The Plan denied your 
request. The Plan says these services are not covered under the benefit package. 
 
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 pre-approve 
reline maxillary partial denture (D5760) and reline complete maxillary denture  (D5750).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot care and associated procedures (28299, 28285, 
27685) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve foot care and associated procedures to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
foot care and associated procedures (28299, 28285, 27685) to be provided by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you have previously suffered from 
diabetes, high blood pressure, gout, and enlarged heart. The Plan denied your request. The Plan says there is no 
documentation that you meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one 
of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have 
to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Soliris. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Soliris is not approved by the Food and 
Drug Administration (FDA) for the enrollee's diagnosis of lung transplant status. The use is not supported by 
one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
The Soliris is not safe and effective or reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Soliris.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation treatment (IMRT) with 
image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IMRT with IGRT. You say that the requested intensity modulated radiation 
treatment (IMRT) with image-guided radiation therapy (IGRT) is medically necessary. The Plan denied your 
request. The Plan says the requested intensity modulated radiation treatment (IMRT) with image-guided 
radiation therapy (IGRT) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IMRT with IGRT. Our reviewer says 
that the requested intensity modulated radiation treatment (IMRT) with image-guided radiation therapy (IGRT) 
is not medically necessary. Our physician reviewer found the record indicates that the enrollee has stage 1E 
gastric MALT lymphoma. There is insufficient literature to support the safety and efficacy of the requested 
service for the enrollees specific clinical condition. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT with IGRT have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intensity modulated radiation treatment (IMRT) with image-guided radiation therapy 
(IGRT).