Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
12, 2021, to May 15, 2021. 
 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported inpatient hospital services with the incorrect DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 872 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITHOUT MCC). 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 services. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found DRG 641: MISCELLANEOUS DISORDERS OF NUTRITION, 
METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC is the appropriate DRG for this 
admission. No clear source of sepsis was documented in the records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from May 12, 2021, to May 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on October 14, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on October 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the femur (73552) provided on November 10, 
2021. 
 
You asked the Plan to pay for the x-ray of the femur. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says this is a duplicate of a previously paid claim. The 
documentation does not support an additional unit of service beyond what has already been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that claims or claim lines that have been determined to be an exact duplicate with respect to certain 
elements are denied and do not have appeal rights. 
 We find that CPT code 73552 is not supported in the medical record. Specifically, this claim is a duplicate of a 
previously submitted claim which has already been paid. The documentation provided does not support an 
additional unit of service on the date in question for this enrollee. Based on this information, we decided that 
Medicare rules for coverage of the x-ray of the femur have not been met. Therefore, we decided that the Plan 
does not have to pay for the x-ray of the femur (73552) provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging 
(92134), provided on October 13, 2021.  
You asked the Plan to pay for the scanning computerized ophthalmic diagnostic imaging. You say that the 
service should be covered. The Plan denied your request. The Plan says there are no records showing that a 
second, separate scan was done. 
 
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 the scanning computerized ophthalmic 
diagnostic imaging (92134), provided on October 13, 2021. have been met. Specifically, there is no evidence 
that the services were rendered twice.. Therefore, we decided that the Plan does not have to pay for the 
scanning computerized ophthalmic diagnostic imaging (92134), provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (99211) provided on 
August 12, 2021. 
 You asked the Plan to pay for an office visit. You say that the code at issue is payable as billed by your office. 
The Plan denied your request. The Plan says rules for payment have not been met because the CPT code at 
issue is inclusive to another billed code. 
 
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 99211 
is a column II code to column I code 99202. 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 an office or other outpatient visit (99211) provided on August 12, 
2021.
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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is 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 enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that she is not currently 
receiving but that would be available at the LTACH facility. 
 
 
 
  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 29, 
2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says all of the asked for details have not been received. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee was reportedly biopsied, but no notes were provided. A macular dark brown-black lesion of 
7.26 mm diameter on the left superior upper back was reportedly found and biopsied. This is a request for 
genetic testing of the lesion sample. However, the provided documentation did not include the physician 
records of examination and biopsy including medical history, documented order for the test, and other support 
for the use of this test. Therefore, the testing will be considered not medically necessary based on the provided 
documentation.   
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 pay for laboratory services provided to the enrollee on December 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of lesion of spermatic cord (55520) provided on 
October 26, 2021. 
 
You asked the Plan to pay for the excision of lesion of spermatic cord (55520). You say that the attached 
medical records support CPT code 55520 being billed. The Plan denied your request. The Plan says the medical 
records received do not support that the procedure was distinct or independent from other services performed. 
 
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 55520 is a column II code to column I code 49520; however, 55520 
was billed with a modifier.  
 
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 excision of lesion of spermatic cord (55520). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found the operative report describes the hernia sac is attached to the cord. Therefore, this procedure 
would be inclusive to the hernia repair procedure code and modifier -59 is not supported. 
 
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 excision of lesion of spermatic cord (55520) have not been met. Therefore, 
we decided that the Plan does not have to pay for the excision of lesion of spermatic cord (55520) provided on 
October 26, 2021.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and are 
currently unstable for transfer to an LTACH. 
 
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. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. All medically necessary care is being provided in the current acute care facility. Our physician 
reviewer found that your condition does not meet Medicare criteria for LTACH services. 
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the eye refraction (92015) provided on February 8, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you feel it is ridiculous that your Plan requires 
you to get certain services from in-network providers when your Plan generally covers out-of-network care. 
The Plan denied your request. The Plan says that routine vision services must be received from a provider 
within the Plan's specified routine vision vendor network. 
 
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 denied payment for this service based on contractual rules 
but did not provide a copy of the contract for the 2022 Plan year. The contract submitted by the Plan is for the 
2021 Plan year and does not apply in this case. Therefore, we decided that the Plan has to pay for the eye 
refraction (92015) provided on February 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on February 11, 2022. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says services 
from non-participating providers are not covered under your Plan unless they are authorized the Plan before the 
services are provided. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services provided on February 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse Generator 
(0408T) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this device is denied because it is considered investigational under our 
Medicare guidelines. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. An exhaustive 
review of the current medical literature pertaining to the cardiac contractility modulation (CCM) system 
confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical 
trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple 
studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional 
capacity. While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies 
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 
these services. 
 
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 an Optimizer Smart Implantable Pulse Generator (0408T) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (95885), nerve conduction studies 
(95907), and unlisted neurological or neuromuscular diagnostic procedures (95999) billed for date of service 
May 10, 2021. 
 
You asked the Plan to pay for needle electromyography, nerve conduction studies, and unlisted neurological or 
neuromuscular diagnostic procedures. You say that you have provided records to support the services billed. 
The Plan denied your request. The Plan says rules for payment have not been met because the available records 
do not support the codes 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 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)"; of code 95907 is "Nerve conduction 
studies; 1-2 studies"; and of code 95999 is "Unlisted neurological or neuromuscular diagnostic procedure." 
 
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 needle electromyography, nerve conduction studies, and 
unlisted neurological or neuromuscular diagnostic procedures. Our reviewer says that the CPT codes at issue 
do not meet criteria for payment in this case. Our reviewer found that the procedure report describes pedicle 
screw stimulation, which would not be reported with CPT code 95907, nerve conduction studies, which 
measure amplitude and latency/velocity. CPT code 95885 is a procedure done with nerve conduction studies. 
As in this case nerve conduction studies cannot be verified, the related procedure would not be covered. 
Finally, the procedure report does not include documentation of an unlisted procedure to confirm code 95999 
being reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of needle electromyography, nerve conduction studies, and unlisted neurological 
or neuromuscular diagnostic procedures have not been met. Therefore, we decided that the Plan does not have 
to pay for needle electromyography (95885), nerve conduction studies (95907), and unlisted neurological or 
neuromuscular diagnostic procedures (95999) billed for date of service May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at home COVID-19 test (87426) and sales tax (S9999) 
purchased December 26, 2021. 
 
You asked the Plan to pay for the COVID-19 test. You say that you would like to appeal the denial for 
reimbursement of a home COVID test. The Plan denied your request. The Plan says these items are not covered 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at 
issue is not enrolled in the Medicare program. Per Medicare.gov: Currently, Original Medicare doesnt pay for 
over-the-counter COVID-19 tests. You can pick up free at--home tests from community health centers and 
Medicare-certified health clinics. Or visit COVIDtests.gov to order a free COVID-19 at home test. 
 
Therefore, we decided that the Plan does not have to pay for the at home COVID-19 test (87426) and sales tax 
(S9999) purchased December 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on September 27, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the code must meet certain requirements for medical necessary for post-operative pain 
management, in which could not be verified. 
 
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 64445 is Injection(s), anesthetic agent(s) and/or steroid; 
sciatic nerve. 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the anesthesiology 
records/photocopies submitted (pages 38-42) are illegible due to poor copy quality. Due to the poor 
quality/illegible anesthesia records, along with a procedure note, with the inability to assess certain 
requirements for CPT 64445-59LT, the postoperative pain management provided by the anesthesiologist, 
cannot be verified. The documentation does not support CPT code 64445-59LT. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services provided to the enrollee on September 27, 2021.