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

 
We decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on July 27, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that the service should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on July 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 5, 2021. 
 
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. 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 82542 is a column II code to column I code 80307. 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 the laboratory services 
rendered on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter. 
 
You asked the Plan to pre-approve a Dexcom G6 transmitter. The Plan denied your request. The Plan says the 
enrollee is either not on insulin three times a day or is not adjusting their insulin dose based on their glucose 
readings. 
 
The Plan follows Medicare rules. The rules say that therapeutic continuous glucose monitors (CGMs) may be 
considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a Dexcom G6 transmitter. Our reviewer 
says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the documentation 
does not show that the enrollee takes insulin at meals, it only shows that the enrollee takes Lantus once daily. 
Our reviewer also found that although the CGM may indeed help the enrollee's blood glucose control and help 
him eat correctly, its use at this time does not meet plan criteria for coverage, as there is no indication in the 
notes that the enrollee is using insulin three times per day, and adjusting doses based on the blood glucose 
level. 
 
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 Dexcom G6 transmitter have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G6 transmitter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 13, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these 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 the laboratory services rendered on June 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 23, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these 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 the laboratory services rendered on March 23, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial hospital care rendered on January 7, 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 that the services are bundled. 
 
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. The Plan states that code 99222 is not separately payable because it is bundled; 
however, there is no documentation of this code being billed with another code. The Plan has not provided any 
documentation or Medicare rules to support that the services are not payable as billed. Therefore, we decided 
that the Plan has to pay for the initial hospital care rendered on January 7, 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 the abdominal ultrasound (76705) provided on January 19, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 the abdominal ultrasound (76705) provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spinal fusion (22612), lumbar laminectomy 
(63047), allograft (20930, 20936), insert spinal fixation device (22840) and scan proc spinal (61783) for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the enrollee does not have a condition for coverage. 
 
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. Dynamic 
flexion/extension films are not provided in order to potentially assess the amount of movement (instability) at 
the requested surgical level. Detailed documentation is not evident regarding potential impending/inevitable 
temporary intra-operative instability. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Our physician reviewer found that the enrollee's condition does not meet criteria for 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 lumbar spinal fusion (22612), lumbar laminectomy (63047), allograft (20930, 20936), 
insert spinal fixation device (22840) and scan proc spinal (61783) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient stay provided from December 14, 2020, to December 16, 
2020. 
 
You asked the Plan to pay for the inpatient stay. You say that the enrollee meets the inpatient criteria, and you 
would like to be reimbursed for the services that were provided. The Plan denied your request. The Plan says 
that these services meet the observation level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 stay. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that at the time of inpatient admission the admitting physician reasonably expected that the patient's 
necessary hospital care (including earlier emergency department and/or observation care) would span two 
midnights. 
 
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 inpatient stay have been met. Therefore, we decided that the Plan has to pay 
for the inpatient stay provided from December 14, 2020, to December 16, 2020.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
home ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the 
enrollee has severe chronic obstructive pulmonary disease (COPD) with chronic hypercarbic respiratory 
failure, documented on arterial blood gas (ABG) done as outpatient. The enrollee has a home ventilator 
currently, and most recent download meets minimum Medicare requirements for use, with 76.7 of days with at 
least 4 hours of use per day.  However, there is no evidence that bipap has been tried and failed.  Bipap can 
provide the Average volume-assured pressure support (AVAPS) mode of support with a backup rate, at less 
cost to the enrollee.  Medicare does not cover a ventilator when used as bipap. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on December 3, 2021. 
 
You asked the Plan to pay for the compression stockings. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says these compression stockings are not 
covered by Medicare or the Plan. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on December 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Injectafer (J1439) provided on August 3, 2021. 
 
You asked the Plan to pay for the Injectafer. You say that the enrollee needed this medication. The Plan denied 
your request. The Plan says the clinical value and effectiveness of Injectafer in the absence of iron deficiency 
anemia have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for Food and 
Drug Administration (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 pay for the Injectafer. Our reviewer says that 
Injectafer is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
requested use of Injectafer (J1439) is not FDA-approved for the enrollees diagnosis. Our reviewer also found 
that its use is not supported by one of the major drug compendia or by clinical research that appears in a 
Centers for Medicare & Medicaid Services approved medical journal. 
 
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 Injectafer have not been met. Therefore, we decided that the Plan does not 
have to pay for the Injectafer (J1439) provided on August 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve videonystagmography to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the diagnostic services. You say that you have been needing to have this 
service done since January. You say that you are no longer able to seek physical therapy until you have this 
testing done. The Plan denied your request. The Plan says the requested evaluations and testing can be done by 
an in-network provider. 
 
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 
videonystagmography to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and materials (99072) provided on 
October 20, 2021. 
 
You asked the Plan to pay for the additional supplies and materials (99072). You say that plans are required to 
pay non-contract providers at the preferred provider rate when services are not available in the service area. 
You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied 
your request. The Plan says bundled services are not eligible for separate payment.  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 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the additional supplies and materials (99072) have not been met. Therefore, we decided that the Plan does 
not have to pay for the additional supplies and materials (99072) provided on October 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from April 8, 2021, through April 
14, 2021, at DRG 871. 
 
You asked the Plan to pay for inpatient services at DRG 871. You say that the physician diagnosed sepsis and 
the patient was treated for sepsis. You say that the assignment of the original diagnosis code and DRG were 
correct, and you expect to be compensated for the services without recoupment. The Plan denied your request. 
The Plan says payment of DRG 871 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 with DRG 871 with a diagnosis code of A41.9 defined as sepsis 
unspecified organism and secondary diagnosis code R65.21 defined as severe sepsis with septic shock. 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 inpatient services at DRG 871. Our reviewer 
says that the documentation does not support the diagnosis codes of A41.9 and R65.21. Our physician reviewer 
found that there was no documentation of sepsis. While the enrollee warranted consideration of sepsis as a 
diagnosis, there was no evidence of life-threatening organ dysfunction due to a dysregulated host response to 
infection.  
 
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 services provided from April 8, 2021, through April 14, 2021, at DRG 871.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections (64483, 64484). 
 
You asked the Plan to pre-approve repeat epidural steroid injections. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested services 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 repeat epidural steroid injections. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that, in this case, the transforaminal ESI was done on April 26, 2022. The review 
has determined that the enrollee does not meet the coverage criteria for a repeat procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat epidural steroid injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repeat epidural steroid injections (64483, 64484).