Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup (D2950) provided on June 13, 2022. 
 
You asked the Plan to pay for the core buildup (D2950). You say that this service was medically necessary. 
The Plan denied your request. The Plan says the code billed is not supported by the records provided. 
 
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 core buildup (D2950) have been 
met. No clinical records were submitted to verify if the code billed is supported. The only information provided was a note from the provider with small radiographs. Therefore, we decided that the Plan does not have to pay 
for a core buildup (D2950) provided on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service July 26, 
2022. 
 You asked the Plan to pay for procedure code 95941. You say that you have provided medical records to 
support payment of this code. The Plan denied your request. The Plan says payment for code 95941 is bundled 
into payment for code G0453. 
 
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 95941 
is a column II code to column I code G0453 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 95941 billed for date of service July 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 13, 2022, to 
April 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The 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 reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 13, 2022, to April 
26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rollator walker provided May 6, 2022. 
 
You asked the Plan to pay for the walker. You say that you disagree with the denial because you were informed 
differently by a Plan associate. The Plan denied your request. The Plan says the item was purchased form a 
supplier that is not a Medicare contracted DME provider. 
 
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. Therefore, we decided that the Plan does not have to pay for the rollator walker provided May 6, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70481 billed for date of service October 27, 
2022. 
 
You asked the Plan to pay for procedure code 70481. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70481 is bundled into payment for 
code 70450. 
 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 70481 
is a column II code to column I code 70450. 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 70481 billed for date of service October 27, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided form November 25, 2021, to December 
24, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the initial Request for 
Anticipated Payments (RAP) claim was not received within 5 calendar days from the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that a timely-filed RAP is submitted to the contractor 
and accepted by the contractor within 5 calendar days after the From date of a HH period of care.  
 
We looked at the file and Medicare rules. In this case, the RAP claim was not submitted to the contractor 
within 5 calendar days after the start of care. 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 
services provided form November 25, 2021, to December 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 88112, 88305, 
88312, and 88361 for March 31, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules state that billing globally for services that are split into PC and 
TC components is only possible when the TC and the physician who provides the PC of the diagnostic service 
are furnished by the same physician or supplier entity and the PC and TC components are furnished within the 
same Medicare physician fee schedule payment locality 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not provided at the same 
payment locality. 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 pay for the laboratory services billed 
with codes 88112, 88305, 88312, and 88361 for March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and supplies provided 
on July 27, 2022. 
 
You asked the Plan to pay for a CGM and supplies. You say that these supplies were medically necessary. The 
Plan denied your request. The Plan says valid proof of delivery was not provided. 
 
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. The delivery form does not include evidence of delivery 
of the specific items billed on this claim to the enrollee. 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 a continuous glucose monitor (CGM) and supplies provided on July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 9, 2021, to June 
15, 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 you 
disagree with the denial. The Plan denied your request. The Plan says the DRG 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 diagnosis code A41.9. 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 submitted records do not support the billing of diagnosis code A41.9. Our physician 
reviewer found the enrollee presented to the emergency department (ED) with abdominal pain, nausea, 
vomiting, and decreased oral intake. He was admitted and after a work-up was diagnosed with duodenitis. The 
laboratory data revealed a platelet count of 221, creatinine of 0.8, and a total bilirubin of 1.1. In addition, his 
mean arterial pressures remained consistently above 70 throughout the admission and there was no indication 
of a decrease in urine output. There is no arterial blood gas to determine an accurate P/F ratio. While he had an 
oxygen saturation of 91 percent on admission, this was in the setting of chronic obstructive pulmonary disease 
(COPD). Therefore, this would not be evidence of dysregulated immune-mediated organ injury. The 
documentation does not support diagnosis code A41.9.  
 
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 June 9, 2021, to June 15, 2021 at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary to help you return to being 
independent as quickly as possible. The Plan denied your request. The Plan says you can receive your care in 
another setting such as a skilled nursing facility. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 services are necessary for the 
enrollee to gain prior level of functioning back through physical and occupational therapy. The Plan denied 
your request. The Plan says the enrollee's care can be provided safely in the current acute care setting. 
 
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 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 health plan. The health plan has approved ongoing care 
in the current acute care setting. All medically necessary care is being provided in the current acute care 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 sensor. The Plan denied your request. The Plan says that 
the coverage criteria has not been met. 
 
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 you do not use insulin with at least 
three daily injections, and you do not 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 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre 2 sensor.
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 enrollee meets LTACH admission 
criteria to sustain a safe and sustainable discharge, this is the best option for care. The Plan denied your request. 
The Plan says when the enrollee is medically stable and no longer requires an acute level of care, the ongoing 
needs for skilled therapy, and skilled nursing may be completed in a less intensive level of care such as a 
skilled nursing facility. 
 
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 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 health plan. 
 
 
 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 lab services (80053, 80061, 82043, 82570, 83036, 84443, 
85025, 86850, 86900, 86901) provided August 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 lab services have been met. No 
clinical or office records were provided. Only lab results were provided for review. Therefore, we decided that 
the Plan does not have to pay for lab services (80053, 80061, 82043, 82570, 83036, 84443, 85025, 86850, 
86900, 86901) provided August 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service September 
6, 2022. 
 
You asked the Plan to pay for procedure code(s) 85060. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this code is included in the facility payment and 
is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 85060. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 85060. Based on this information, 
we decided that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service September 6, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytogenetics and molecular cytogenetics, interpretation and 
report (88291) provided June 13, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the treating physician in this case, who is 
part of the Plan's network of participating providers, considered your expertise and specialized testing crucial to 
treating the enrollee's complex medical condition. The Plan denied your request. The Plan says a provider must 
be enrolled in the Medicare program in order to receive payment 
 
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. Therefore, we decided that the Plan does not have to pay for cytogenetics and molecular cytogenetics, 
interpretation and report (88291) provided June 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 CGM. 
 
You asked the Plan to pre-approve the CGM. The Plan denied your request. The Plan says that the coverage 
criteria has not been met. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 1, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services billed with codes 98941, 97110, 97140, 
97035, 97032, 97012, and 97112. 
 
You asked the Plan to pay for codes 98941, 97110, 97140, 97035, 97032, 97012, and 97112. You say that these 
were necessary and effective chiropractic services and the claim should be paid. The Plan denied your request. 
The Plan says codes 97110, 97140, 97035, 97032, 97012, and 97112 are not covered chiropractic services.  In 
addition, the Plan says that you did not bill the appropriate modifier for code 98941. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. In addition, the rules say that claims for code 98941 
must have the AT modifier appended to them in order to be covered. 
 The records show that codes codes 97110, 97140, 97035, 97032, 97012, and 97112 do not represent manual 
manipulation of the spine. Further, records show that you did not bill code 98941 with the AT modifier as is 
required. Therefore, we decided that the Plan does not have to pay for chiropractic services billed with codes 
98941, 97110, 97140, 97035, 97032, 97012, and 97112.