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

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service January 10, 
2022. 
 
You asked the Plan to pay for procedure code 93971. The Plan denied your request. The Plan says payment for 
code 93971 is bundled into payment for code 93970.  
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 93971 
is a column II code to column I code 93970. 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 93971 billed for date of service January 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA), nerves innervating the 
sacroiliac joint, with image guidance (64625). 
 
You asked the Plan to pre-approve the RFA. You say that the enrollee had two test block injections (27096) 
with great response. You say that the final procedure, radiofrequency ablation, should be approved. You also 
say that there does not seem to be a reason to deny this service. The Plan denied your request. The Plan says 
sacral lateral nerve branch blocks and/or ablations to treat pain in the joint that connects the pelvis to the 
tailbone (sacroiliac joint) are not supported by research and not covered. 
 
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 the RFA. Our reviewer says that the 
requested radiofrequency ablation is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a wide variation in efficacy reported in the literature. The reviewer found that 
the requested treatment is considered experimental and investigational. Therefore, the reviewer found that the 
requested service 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA), nerves innervating the sacroiliac joint, with image guidance 
(64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the compression stockings provided on 
October 13, 2021. 
 
You asked the Plan to waive the cost share for the compression stockings. You say that this is a 100% covered 
benefit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance for the compression stockings for a total of $55.24 ($276.20 
total charge x 20% coinsurance = $55.24). The compression stockings fall within the Durable Medical 
Equipment (DME) and Related Supplies 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 cost share 
for the compression stockings provided on October 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90837) provided on August 31, 
2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical 
necessity for you. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 psychotherapy services (90837) 
provided on August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 23, 2021. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on June 23, 2021.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely in other settings. 
 
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. The 
enrollee is medically stable and does not need physical medicine and rehabilitation physician's close 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute nursing needs identified or documented. At the current 
functional level, the enrollee does not need therapy 3 hours a day, 5 days a week. While the enrollee would 
benefit from physical and occupational therapy the enrollee's rehab needs can be safely provided in an alternate 
and low intensity setting. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for IRF 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory testing provided on March 
24, 2022. 
 
You asked the Plan to waive the copayment for the laboratory testing. You say that you never had a copay 
before and do not understand why you are getting one now. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
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 $10 
copayment per day for laboratory testing.  
 
You have been asked to pay a $10 copayment for the laboratory testing. The laboratory tests fall within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 the laboratory testing provided on March 24, 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 March 30, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. 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 March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.  
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that hyperbaric oxygen therapy is 
medically necessary. The Plan denied your request. The Plan says hyperbaric oxygen therapy does not meet the 
Medicare NCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 hyperbaric oxygen therapy. Our 
reviewer says that hyperbaric oxygen therapy is not medically necessary. Our physician reviewer found that the 
enrollee is a 77-year-old male with diabetes and has had a left trans-metatarsal amputation and a right below 
the knee amputation. The enrollee has been in active wound management since May 2021 for a left medical 
calcaneal diabetic ulcer. There have been times when the enrollee has been noncompliant with wound care 
appointments, most appear to be related to transportation issues. According to the submitted information the 
enrollee has responded variably to Hydrometra blue, Epfix, Puraply, and every "advanced product." Evaluation 
by a vascular surgeon indicates that the enrollee has good perfusion. The MRI on May 24, 2022 did not show 
signs of osteomyelitis. The enrollee's wound has now progressed. The review has determined that the requested 
hyperbaric oxygen therapy does not meet the Medicare NCD coverage criteria. The review indicates that the 
enrollee does not have a Wagner grade III ulceration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on February 21, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because 
the outpatient services at issue were billed with an inpatient place-of-service (POS) code. 
 
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 denied stating that the outpatient claim was 
erroneously billed with inpatient POS 22. However, POS 22 indicates an outpatient setting. It is the Plan's 
responsibility to substantiate its denial. In this case, the denial has not been substantiated, so we must find in 
your favor. Therefore, we decided that the Plan has to pay for laboratory services provided on February 21, 
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 the genetic testing provided on March 3, 2022. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. The testing was billed with multiple codes on multiple claims. Based on this information, we 
decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the genetic testing provided on March 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has had several nights in the 
intensive care unit due to severe chronic obstructive pulmonary disease with chronic exacerbation and is still 
on oxygen. You say that it is not safe for the enrollee to go home until the oxygen need goes down. The Plan 
denied your request. The Plan says based on Medicare guidelines the LTACH services you are requesting do 
not meet the requirements for approval. 
 
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 the enrollee was admitted with sepsis. The record indicates that the enrollee still 
requires acute care services before transitioning to a lower level of care. The enrollee is receiving appropriate 
care at the present setting. The enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided on April 19, 
2022. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this item is not covered under your contractual 
policy. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the item provided is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic 
crown (D2740) provided on April 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from January 10, 2021, through 
January 13, 2021, at DRG 246. 
 
You asked the Plan to pay for inpatient services at DRG 246. You say that the documentation clearly indicates 
the dissection was not intentional and significant enough to warrant a return to the lab. You say that the code is 
warranted and should be reconsidered. The Plan denied your request. The Plan says diagnosis code I25.42 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 diagnosis code I25.42, defined as coronary artery dissection. 
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 246. Our reviewer 
says that the documentation does not support diagnosis code I25.42. Our physician reviewer found that the 
medical records do not support the dissection to be a complication of the procedure, nor does the 
documentation support the condition to be clinically significant.  
 
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 January 10, 2021, through January 13, 2021, at DRG 246.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from September 12, 2021, 
through September 16, 2021, at DRG 871. 
 
You asked the Plan to pay for inpatient services at DRG 871. You say that the medical record clearly supports 
the clinical diagnoses, and you disagree with the removal of the diagnosis codes. You say that the 
documentation supports the DRG as billed, and payment of the entire claim should be approved. The Plan 
denied your request. The Plan says principal diagnosis code A41.9 and secondary diagnosis code R65.20 are 
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 principal diagnosis code A41.9, defined as sepsis, 
unspecified and secondary diagnosis code R65.20, defined as severe sepsis without 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 principal diagnosis code A41.9 and secondary diagnosis code R65.20. Our 
physician reviewer found despite presentation with suspected pneumonia, colitis with diarrhea, and elements of 
Systemic Inflammatory Response syndrome, the hospital record does not support reporting the diagnosis codes 
for sepsis and severe sepsis.  
 
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 September 12, 2021, through September 16, 2021, at DRG 871.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 1, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you disagree with the denial. 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 April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on April 18, 2022, by an 
out-of-network (OON) provider.