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

 
We decided that the Plan has to pre-approve inpatient admission. 
 
You asked the Plan to pre-approve inpatient admission. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the requested inpatient services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 inpatient admission. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee presented to the emergency department (ED) on January 18, 2023 from a 
rehabilitation facility after an unwitnessed fall. The enrollee was evaluated in the ED with a physical exam, 
laboratory studies and diagnostic imaging- computerized tomography (CT) head and neck, and CT 
abdomen/pelvis/video swallow. The enrollee was started on intravenous (IV) antibiotics and admitted. The 
enrollee underwent evaluations by Cardiology, Gastroenterology, Urology, and Neurology. Therefore, the 
enrollee has a diagnosis/condition that meets criteria for inpatient admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission have been met. Therefore, we decided that the Plan has to 
pre-approve inpatient admission.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 91065 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 91065. 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 91065 is 2. The MAI value for this code is 2. You billed 6 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 91065 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 91065 billed for date of service September 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the forearm splint (29125) provided on August 10, 2021. 
 
You asked the Plan to pay for the physician service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says that the diagnosis code does not support the service that was provided. 
 
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 provided documentation does not support the reason for denial 
of this service. Therefore, we decided that the Plan has to pay for the forearm splint (29125) provided on 
August 10, 2021.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 29, 2022, to 
May 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that only one NOA is required, and 
one was submitted with a date of January 29, 2022. 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 29, 2022, to May 
28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496.  
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 14, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
13, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service September 13, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble metal (D6240) 
Tooth #3 and 7 and retainer crown - porcelain fused to high noble metal (D6750) Tooth #2, 4, 5, 6, 8, 9 and 10. 
 
You asked the Plan to pre-approve dental services. You say that you need to change the removable tooth that 
you have had since you were 30 years old. The Plan denied your request. The Plan says the denial of this 
services is based on the reason that the requested services do not comply with the established dental clinical 
criteria. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
services when the services are medically necessary and reasonable.  
 
  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 dental services. Our physician reviewer 
found the documentation provided does not meet the criteria for coverage of medically reasonable and 
necessary for a fixed bridge replacing teeth #'s 3 and 7 with pontic (D6240) using teeth #'s 2, 4, 5, 6, 8, 9, and 
10 as abutment retainers (D6750). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pontic - porcelain fused to high noble metal (D6240) Tooth #3 and 7 and retainer crown - 
porcelain fused to high noble metal (D6750) Tooth #2, 4, 5, 6, 8, 9 and 10.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test provided on June 17, 2022. 
 
You asked the Plan to pay for the Guardant360 test. You say that this 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 Guardant360 test provided on June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on June 09, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for podiatry services. 
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls within the podiatry 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on 
June 09, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI), spinal canal and contents, 
lumbar; without contrast material (72148). 
 
You asked the Plan to pre-approve an MRI of the spine. You say that you are in a lot of pain and have taken 
medication to assist with this pain. You also stated that doing six weeks of physical therapy would not help 
your situation. The Plan denied your request. The Plan says that an MRI is not reasonable or medically 
necessary and does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 an MRI of the spine. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a more acute flair of 
chronic low back pain. You also presented with a new phenotype of your low back pain (which had not been 
previously exhibited). Medicare says that MRIs are covered when reasonable and necessary. In this case based 
on the records provided for review, the requested study can be adjudged to be reasonable and necessary. Also, 
based on the pain management consult note, the findings of the study will be used to guide a determination on a 
potential interventional pain management procedure. Therefore, this would meet requirements for coverage. 
 
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 MRI of the spine have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI), spinal canal and contents, lumbar; without contrast material 
(72148).  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for endovascular revascularization (procedure code 37229) provided to the 
enrollee on July 22, 2022. 
 
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 that the records do 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. In this case, the CPT Code Manual definition of 
code 37229 is "Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial 
vessel; with atherectomy, includes angioplasty within the same vessel, when performed." 
 
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 supported by the medical records. Our reviewer found that CPT 37229 codes for tibial 
atherectomy with or without balloon angioplasty.  Documentation of balloon angioplasty is not a requirement 
to use this code. There is satisfactory documentation of a high-grade stenosis in the proximal anterior tibial 
artery that was treated with atherectomy. While the result of the atherectomy to the anterior tibial artery could 
have been described more clearly, the documentation reaches a minimum threshold to justify use of the code. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
endovascular revascularization (procedure code 37229) provided to the enrollee on July 22, 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 76642 billed for date of service September 1, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this should be paid for. 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 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for exploration of spinal fusion provided to the enrollee on 
March 7, 2022. 
 
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 operative report did not support this service as an independent procedure. 
 
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 22830 is "Exploration of spinal fusion." 
 
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 that exploration of fusion is not 
properly described in the operative note. Additionally, the code is included in the fusion code for the same 
level. 
 
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 exploration of spinal fusion provided to the enrollee on March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E0431). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the requested code is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that when code K0738 is billed, code E0431 (portable 
gaseous oxygen system, rental) must not be used. 
 
We looked at the file and Medicare rules. Code K0738 was already approved for 12 months starting in June 
2022. Based on this information, we decided that Medicare rules for coverage of the portable oxygen 
concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable 
oxygen concentrator (E0431).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure codes 63655 and 63685) provided to the 
enrollee on June 8, 2022. 
 
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 that the records do 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. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 63655: 
 
Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 
 
CPT 63685: 
 
Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 
 
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 supported by the medical records. Our reviewer found that in terms of CPT 63655, the procedure 
details cite the spinous processes of T11 and T12 were removed using Leksell rongeurs. A laminectomy was 
performed in order to facilitate placement of the Nevro open paddle lead using 33 Kerrison rongeurs and the 
3.0 neuro tip of the Stryker drill. Following the laminectomy at the T11-12, the hockey stick instrument was 
provided in the Nevro spinal cord stimulator implantation kit was used to gently lyse the adhesions up under 
the T9 and T10 lamina to facilitate the placement of the paddle lead. This supports that the CPT 63655: 
laminectomy for implantation of neuromuscular electrodes, plate/paddle, epidural was rendered in this case. 
Concerning CPT 63685, the procedure details cite blunt dissection with a finger was used to create a pocket in 
the subcutaneous fat for the generator. A tunneler was used to tunnel a path from the generator site to the 
posterior thoracic incision. The distal portion of the leads in the incision in the left flank was connected to the 
spinal cord stimulator generator. The generator was placed into the pocket and sutured. This supports that the 
that CPT 63685: insertion or replacement of spinal stimulator pulse generator or receiver, direct or inductive 
coupling was rendered in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure codes 63655 and 63685) provided to the enrollee on June 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 7, 2021, to January 10, 2022. 
 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 services were billed at an intensive/progressive care unit rate, instead of the more appropriate 
medical/surgical room-and-board rate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our 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 reviewer found that the clinical documentation 
does not support that it was medically reasonable and necessary for the enrollee to receive care at an intensive 
care unit level. The enrollee's management could have been appropriately provided at a medical/surgical unit 
level of care. The enrollee was not critically ill, with a serious illness or injury that required special life-saving 
techniques. 
 
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 inpatient hospital services provided to the enrollee from December 7, 2021, to January 10, 
2022.