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

 
We decided that the Plan has to pay for the oncology (prostate), mRNA expression profiling (0339U) provided 
on November 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says that there is insufficient information to review the medical necessity of this service. 
 
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 required medical records to review the claim for medical necessity. We 
found no evidence in the case file that requests were sent to the provider for this additional information. Thus, 
we cannot verify that the Plan has made reasonable and diligent efforts to gather this information. Therefore, 
we decided that the Plan has to pay for the oncology (prostate), mRNA expression profiling (0339U) provided 
on November 2, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 16, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says more information is needed. 
 
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 that the physician order is for a standard urinalysis with reflex culture and sensitivity, not a 
genetic/molecular urinary tract infection panel. There is no provider evaluation to support why any test was 
necessary or ordered. The acquisition of a genetic/molecular urinary tract infection (UTI) test to diagnose 
and/or manage a UTI is not medically reasonable or necessary. 
 
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 August 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (12052) provided on September 26, 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 12052 is not supported in the medical record. Specifically, the records do 
not show that the treating physician performed post-operative care. CPT code 12052 has a 10-day global 
period. As such, modifier -54 should be used in this case. 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 (12052) provided on September 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous infusion coded 96365 provided on May 9, 
2022. 
 
You asked the Plan to pay for the intravenous infusion. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. 
 
We find that CPT code 96365 is not supported in the medical record. Specifically, this code was billed with 
procedure code B96.5 (Pseudomonas (aeruginosa)). The disease that was classified elsewhere has to be coded 
first. Diagnosis B96.5 is not a primary diagnosis code and cannot be used as primary.  Based on this 
information, we decided that Medicare rules for coverage of the intravenous infusion have not been met. 
Therefore, we decided that the Plan does not have to pay for the intravenous infusion coded 96365 provided on 
May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on August 9, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that there is no 
evidence to support the ordering provider ordered the service. 
 
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 argues that there is no evidence to support that the supplies were 
ordered. However, the records show that a prescription was signed by the ordering provider on July 8, 2021, for 
a Zynex NexWave and supplies. This prescription recorded a lifetime "length of need". As the records contain 
a valid order for the supplies in question, the Plan's denial cannot be substantiated. Therefore, we decided that 
the Plan has to pay for the electrical stimulator supplies provided on August 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on May 25, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and accessory 
provided on August 2, 2022. 
 
You asked the Plan to pay for the PCD and accessory. The Plan denied your request. The Plan says the PCD 
was provided for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) and accessory provided on August 2, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on August 19, 2022. 
 
You asked the Plan to pay for the services at issue. You say that these services were necessary and there is no 
indication that these services required authorization. The Plan denied your request. The Plan says that these 
services were provided out-of-network, and out-of-network care is not covered. 
 
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 case file provided is incomplete and it is not clear that the Plan 
has conducted a thorough review of the services at issue. The Plan did not include a copy of the original claim 
as it was submitted for payment, including a list of the Current Procedural Terminology (CPT) codes of the 
services at issue. It appears that the care provided in this case is outpatient care, although there is some 
discrepancy of this in the information provided by the Plan. Although the Plans rules do indicate that out-of-
network services are only covered in certain limited circumstances, it does not appear that the Plan has 
reviewed whether these services were urgent/emergent or referred by a network provider. Because the Plan has 
failed to provide evidence of a complete review of these services as required, the Plans denial is not 
substantiated in this case. Therefore, we decided that the Plan has to pay for the services provided on August 
19, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillectomy services coded 31225 provided on August 
3, 2022. 
 
You asked the Plan to pay for the maxillectomy services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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 31225 is maxillectomy; without orbital exenteration. 
 
We find that CPT code 31225 is not supported in the medical record. Specifically, code 31225 is an inpatient 
only procedure. This code was incorrectly billed on an outpatient claim. Therefore, this claim is not payable as 
billed. Based on this information, we decided that Medicare rules for coverage of the maxillectomy services 
have not been met. Therefore, we decided that the Plan does not have to pay for the maxillectomy services 
coded 31225 provided on August 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone density study provided on September 27, 2022 
reported with diagnosis code Z78.0. 
 
You asked the Plan to pay for the bone density study as billed. You say that the claim was billed properly and 
should be paid The Plan denied your request. The Plan says documentation does not support the codes billed. 
 
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 bone density study as billed have 
been met. Specifically, the diagnosis code reported, Z78.0, is defined as asymptomatic menopausal state, and 
the enrollees sex is shown to be male. Neither the claim nor the medical records provides an explanation for 
the conflict between the female diagnosis code and the enrollees reported sex.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the photopheresis, extracorporeal procedure provided on 
April 22, 2022. 
 
You asked the Plan to pay for the photopheresis, extracorporeal procedure. The Plan denied your request. The 
Plan says under Medicare guidelines, your request is not a covered benefit because the records do not show that 
the extracorporeal photopheresis was provided under a clinical research study. We reached out to the provider 
to get additional information regarding any trials the enrollee might be a part of, but we did not receive any 
additional information. 
 
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 photopheresis, extracorporeal 
procedure have been met. Specifically, no documentation of a clinical research study has been provided to 
confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to 
pay for a photopheresis, extracorporeal procedure provided on April 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home or residence visit for the evaluation and 
management of an established patient provided on August 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home or residence visit for the evaluation and management of an established 
patient. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services rendered are not a covered benefit. 
 
 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home or residence visit for the evaluation and 
management of an established patient provided on August 9, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for elbow orthosis (eo), with adjustable position locking joint(s), 
prefabricated, off-the-shelf provided to the enrollee on August 31, 2022. 
 
You asked the Plan to pay for the services. You say that this shouldb e paid for. The Plan denied your request. 
The Plan says the documentation did not sufficiently support the billed supply code. 
 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 that in this case, the documentation doesn't clearly indicate that the enrollee has a diagnosis or medical 
condition that would require the requested elbow orthosis. 
 
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 elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off-the-shelf 
provided to the enrollee on August 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that a delay in treatment could jeopardize the enrollee's 
overall health and their ability to regain maximum functions. The Plan denied your request. The Plan says the 
medical necessity criteria for a SNF admission have not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy and does not meet severity of illness or 
intensity of service criteria on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to reimburse you for psychotherapy provided on June 10, 2022. 
 
You asked the Plan to reimburse you for psychotherapy. The Plan denied your request. The Plan says that you 
do not have to pay this. Medicare policy does not cover this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule or a Plan rule to 
substantiate their denial. Therefore, we decided that the Plan has to reimburse you for psychotherapy provided 
on June 10, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with code 30117 for July 14, 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 3, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the surgical services billed with code 30117 for July 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service September 
26, 2022. 
 
You asked the Plan to pay for procedure code 36000. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 36000 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 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service September 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on 
October 7, 2021, to October 22, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the removal of code A40.9. The Plan denied your request. The Plan says after consideration of all submitted documents, and as a result of this re-review of the clinical evidence, they are upholding the decision 
to remove code A40.9 and to sequence K75.0 (abscess of liver) as the principal diagnosis. 
 
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 871. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the documentation does not indicate that the treatment ordered by the treating medical providers supported 
a primary diagnosis code A40.9 (streptococcal sepsis, unspecified). In this case, the documentation does not 
consistently and completely support the assigned principal diagnosis code with DRG. The replacement of DRG 
is upheld as it is supported by the medical documentation.  
 
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 on October 7, 2021, to October 22, 2021.