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

 
We decided that the Plan has to pay for procedure code 76641 billed for date of service September 9, 2022. 
 
You asked the Plan to pay for procedure code 76641. 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. 
 
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 has denied with the rationale that the unit of service 
exceeds the MUE value and the MAI value is 2. We found that the MUE for CPT code 76641 is 2. You billed 2 
units of this code. This code does not exceed the MUE as billed. The Plan has not indicated any other rationales 
for denial. It is the Plan's responsibility to substantiate its denial with evidence. In this case, the Plan's denial 
has not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for 
procedure code 76641 billed for date of service September 9, 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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the ultrasound services coded 76641 provided on September 1, 2022. 
 
You asked the Plan to pay for the ultrasound services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that this code has a MUE of 1. 
 
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 76641 is ultrasound, breast, unilateral, real time with image documentation, including axilla when 
performed; complete. The MUE for CPT code 76641 is 2. The MAI value for this code is 2. 
 
We find that 2 units of CPT code 76641 are supported in the medical record.  Specifically, the Plan states that 
code 76641 has a MUE of 1 but billed 2 units. Per the Medicare National Correct Coding Initiative Policy 
Manual, code 76641 has a MUE of 2. This means 2 units of this code can be billed. No other denial rationale 
was provided. The Plan did not substantiate their denial. Based on this information, we decided that Medicare 
rules for coverage of the ultrasound services have been met. Therefore, we decided that the Plan has to pay for 
the ultrasound services coded 76641 provided on September 1, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 36589 billed for date of service August 29, 2022. 
 
You asked the Plan to pay for procedure code 36589. You say that this service was reported correctly and is 
supported in the medical record. The Plan denied your request. The Plan says that this code has a status 
indicator of "B" on the Physician Relative Value File, which means that this service is always bundled and 
cannot be paid separately. 
 
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 Physician Relative Value File released in July of 2022 shows 
that procedure code 36589 has a status indicator of "A". Codes with a status indicator of "A" are active codes 
which are paid separately. The Plan's denial is not substantiated in this case. Therefore, we decided that the 
Plan has to pay for procedure code 36589 billed for date of service August 29, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service June 30, 
2022. 
 
You asked the Plan to pay for procedure code 76942. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 76942 is bundled into payment for 
code 76882. 
 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 76942 
is a column II code to column I code 76882. 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 76942 billed for date of service June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve an SI joint injection. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 SI joint injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided record indicates that the sacroiliac joint is without tenderness and 
documents negative results from provocative testing. 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 an SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 70544 is bundled into payment for code 70551.  
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service July 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this service was medically necessary. 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 August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 You asked the Plan to pre-approve a manual wheelchair. The Plan denied your request. The Plan says backup 
chairs are not reasonable or necessary. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that an ultra-lightweight manual wheelchair was requested. The records note the enrollee uses a 
power wheelchair and a manual wheelchair. The enrollee is not a full-time manual wheelchair user. Backup 
chairs are not covered. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 7, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this claim was denied in error. 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 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 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 September 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87186) provided on March 26, 2022. 
 
You asked the Plan to pay for lab services. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the documentation does 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. 
 
We find that CPT code 87186 is not supported in the medical record. Specifically, documentation provided did 
not include lab test results for this service. Based on this information, we decided that Medicare rules for 
coverage of lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (87186) provided on March 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
and supplies. 
 
You asked the Plan to pre-approve a CPAP device and supplies. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
{The Plan follows Medicare rules. Medicare rules say that a CPAP device is covered for the treatment of 
obstructive sleep apnea (OSA) if criteria are met. 
 
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 CPAP device and supplies. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found a replacement PAP 
device is considered not medically necessary because criteria are not met. This enrollee has severe Obstructive 
sleep apnea (OSA) and was prescribed CPAP in late 2021. The clinic visit of September 8, 2022 indicates the 
patient has been on CPAP since 2/2022. Notes suggest the device is not working, but there is no indication that 
the device has been assessed by the vendor to see if repairable. The device is not yet 5 years old. There is no 
download to document usage criteria have been met at any point. At this point the device needs to be assessed 
for repairability. 
 
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 CPAP device and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on April 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim was submitted correctly and should be 
paid. 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 (81479) provided on April 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exploration of spinal fusion coded 22830 and the anterior 
instrumentation services coded 22845 provided on June 29, 2022. 
 
You asked the Plan to pay for the exploration of spinal fusion and the anterior instrumentation services. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed 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. 
 
We find that CPT codes 22830 and 22845 are not supported in the medical record. Specifically, the operative 
report did not include documentation of an exploration of spinal fusion; therefore, code 22830 cannot be 
verified.  The operative report did not include documentation of anterior instrumentation for 2 to 3 vertebral 
segments; therefore, code 22845 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the exploration of spinal fusion and 
the anterior instrumentation services have not been met. Therefore, we decided that the Plan does not have to 
pay for the exploration of spinal fusion coded 22830 and the anterior instrumentation services coded 22845 
provided on June 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 1, 2022, through 
June 30, 2022. 
 
You asked the Plan to pay for home health services. The Plan denied your request. The Plan says the claim was 
submitted with the incorrect admission date. 
 
  The Plan must follow Medicare rules. Medicare rules say that for home health services that are continuing from 
2021, a NOA must be submitted for the first period of care in 2022, using the first date of the period as the 
admission date. Subsequent claims must report this new date as the admission date in order for the claim to 
be matched to the correct NOA.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the claim has been billed with an incorrect 
admission date. Therefore, we decided that the Plan does not have to pay for home health services provided 
from June 1, 2022, through June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high protein oral supplements (B4150). 
 
You asked the Plan to pre-approve the high protein oral supplements. You say that these items are medically 
necessary. The Plan denied your request. The Plan says oral nutritional supplements are not a covered item. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve high protein oral supplements (B4150).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer covering for a prothesis (L5962). 
 
You asked the Plan to pre-approve a protective outer covering. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that when a below knee preparatory prefabricated 
prosthesis (L5535) is provided, prosthetic substitutions and/or additions of procedures are covered in 
accordance with the functional level assessment except for codes L5620, L5629, L5645, L5646, L5670, L5676, 
L5704, and L5962 which will be denied as not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a protective outer covering. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the additional cover 
is not medically necessary. The enrollee is not exposed to a harsh environment and there is no medical 
necessity for the cover. 
 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 protective outer covering have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a protective outer covering for a prothesis (L5962).
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 29, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this service was medically necessary. 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 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission is medically necessary. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 medical record does not indicate that the enrollee requires services that they 
are not currently receiving but would be available at the LTACH facility. The enrollee has continued acute 
medical issues and still requires acute care services before transitioning to a lower level of care.  
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) rendered on 
February 3, 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. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary 
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device (PCD) rendered on February 3, 2022.