Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81404, 81479) provided March 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that 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 (81404, 81479) provided March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive air pressure (CPAP) machine (E0601, 
S9999) provided July 23, 2021. 
 
You asked the Plan to pay for the CPAP machine. You say that the CPAP was medically necessary. The Plan 
denied your request. The Plan says this item is only covered for rental and not purchase. 
 
The Plan must follow Medicare rules. Medicare rules say that is considered a capped rental item, meaning it 
must be rented and cannot be purchased. 
 
We looked at the file and Medicare rules. The CPAP machine was purchased and is only covered for rental. 
Based on this information, we decided that Medicare rules for coverage of the CPAP machine have not been 
met. Therefore, we decided that the Plan does not have to pay for a continuous positive air pressure (CPAP) 
machine (E0601, S9999) provided July 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. 
 
You asked the Plan to pre-approve IRF care. You say that you need rehab so you can live by yourself. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
- and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93976 billed for date of service January 28, 
2022. 
 
You asked the Plan to pay for procedure code 93976. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 93976 is bundled into payment for 
code 76856. 
 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 93976 
is a column II code to column I code 76856. 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 93976 billed for date of service January 28, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue by 
radiofrequency water vapor thermotherapy. 
 
You asked the Plan to pre-approve transurethral destruction of prostate tissue by radiofrequency water vapor 
thermotherapy. You say that the services are necessary. The Plan denied your request. The Plan says based on 
the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that water vapor thermal therapy uses convective water 
vapor energy to ablate prostatic tissue. 
 
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 transurethral destruction of prostate 
tissue by radiofrequency water vapor thermotherapy. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found the enrollee mentioned on February 24, 2022 that they no longer 
wanted a surgical intervention as their symptoms were controlled well with the use of Flomax. Therefore, this 
request for transurethral destruction of prostate tissue procedure will be considered not medically necessary at 
this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral destruction of prostate tissue by radiofrequency water vapor 
thermotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 
transurethral destruction of prostate tissue by radiofrequency water vapor thermotherapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for teledentistry services (D9995) provided on February 17, 
2022. 
 
You asked the Plan to pay for teledentistry services. You say that you were not told this would be a separate 
charge. The Plan denied your request. The Plan says this service is not covered. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
teledentistry services (D9995) provided on February 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from February 5, 2021, 
through March 4, 2021. 
 
You asked the Plan to pay for inpatient hospital care. You say that the provider submitted supporting 
documentation for reconsideration of DRG adjustment. The Plan denied your request. The Plan says an 
itemized bill was requested and not provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient hospital care provided from February 5, 2021, through March 4, 2021. have been met. The provider did not submit that itemized bill as 
requested, the provider failed to meet the obligation to submit sufficient information to determine whether 
payment is due and the amount of payment. Therefore, we decided that the Plan does not have to pay for 
inpatient hospital care provided from February 5, 2021, through March 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 21, 
2021. 
 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 January 21, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard, multiple power 
option (K0861) and accessories (E2361, E1028, E2377, E2313, E1007, E2300, E2620, E2311, E0955, E1010, 
E0956, E2603). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested power 
wheelchair is medically necessary. The Plan denied your request. The Plan says the requested power 
wheelchair does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is 
documentation you have a personal mobility deficit that impairs participation in mobility related activities of 
daily living such as toileting, feeding, grooming, and bathing in customary locations within the home. There is 
documentation that your mobility deficit cannot be helped using a walker, cane, or manual wheelchair due to 
your level of weakness. You can safely operate a power mobility device. Records do not support that you are at 
high risk for skin breakdown with no current pressure ulcer, no history of pressure ulcer or flap surgery. There 
is no history of need for bladder self-catheterization or increased muscle tone or spasticity to support need for 
the requested power tilt/recline. Thus, the multiple power options do not meet criteria for approval. The 
requested E2300 seat elevator is statutorily non-covered. Provided records document that you have 4-/5 to 5/5 
upper extremity strength thus indicating you have adequate upper extremity strength to operate the 
wheelchairs power options with their own switches. Records do not indicate that you have been approved for a 
ventilator. A group 3 power wheelchair with no power option appears indicated in this case. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 3 standard, multiple power option 
(K0861) and accessories (E2361, E1028, E2377, E2313, E1007, E2300, E2620, E2311, E0955, E1010, E0956, 
E2603).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility services provided from September 1, 2021, 
to September 17, 2021. 
 
You asked the Plan to pay for skilled nursing services. You say that this claim is showing as paid but paid at 
$0. This is a skilled nursing claim, and it is unclear why it is being "paid" at $0. The Plan denied your request. 
The Plan says that their claims department has reviewed the claim and confirmed that with the information 
billed, there is no allowable as per their system. 
 
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. In this case, the Plan has not produced a clear and coherent argument or 
explanation as to why this claim was denied. In addition, the Plan has not provided any evidence, rules or 
citations to substantiate their denial. Therefore, we decided that the Plan has to reprocess this claim and pay for 
the skilled nursing facility services provided from September 1, 2021, to September 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy of 105 genes provided on June 
14, 2021. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this was medically necessary testing 
that should be paid. The Plan denied your request. The Plan says this is not billed with the correct POS code. 
 
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 Tempus xF liquid biopsy 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 Tempus xF liquid biopsy of 105 genes provided on June 
14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on 
November 16, 2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on November 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient rehabilitation facility (IRF) services provided from 
March 29, 2021, to April 13, 2021. 
 
You asked the Plan to pay for IRF care. You say that these services are supported in the record. The Plan 
denied your request. The Plan says this claim was not billed with a valid CMG and 0024 revenue code as 
required by Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this 
case, the claim for IRF services was billed without revenue code 0024. 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 pay for inpatient rehabilitation facility (IRF) services provided from March 29, 2021, to April 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 24, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 procedure code 76705 billed for date of service January 24, 
2022.
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 this home ventilator is medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 requested home ventilator is not medically reasonable and necessary. Our physician reviewer found 
based on the medical records provided there is documentation that this patient has chronic respiratory failure 
consequent to chronic obstructive pulmonary disease. There is no documentation that the home mechanical 
(portable) ventilator to be used in average volume-assured pressure support mode meets Medicare criteria for medically necessary and reasonable for this patient. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service January 15, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service January 15, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 14, 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 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 6, 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. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on November 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier, per site 
(D4266), bone graft at time of implant placement (D6104), and extraction, erupted tooth requiring removal of 
bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided 
December 7, 2021. 
 
You asked the Plan to pay for the guided tissue regeneration, bone graft and tooth extraction. You say that your 
provider told you the services would be covered. The Plan denied your request. The Plan says these services 
are not covered under your benefits. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
guided tissue regeneration - resorbable barrier, per site (D4266), bone graft at time of implant placement 
(D6104), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including 
elevation of mucoperiosteal flap if indicated (D7210) provided December 7, 2021.