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

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from April 10, 2022, 
through April 12, 2022. 
 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay 
clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect 
DRG. 
 
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 189. 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 in this case there was no clinical or laboratory evidence of acute respiratory failure with hypoxia. The 
review has determined that the documentation did not support diagnosis code J96.01 - acute respiratory failure 
with hypoxia. The records more support DRG 202.  
 
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 rendered from April 10, 2022, through April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99203 provided on October 3, 2022. 
 
You asked the Plan to pay for the office visit coded 99203. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99203 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and low 
level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on 
the date of the encounter. 
 
We find that CPT code 99203 is not supported in the medical record. Specifically, this code is included in the 
payment of the other services performed on the same date of service, for the same enrollee, and by the same 
provider. This means this code is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the office visit coded 99203 have not been met. Therefore, we decided that the Plan does 
not have to pay for the office visit coded 99203 provided on October 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee's needs can be met in the current hospital setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the maxillofacial 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CT scan of the maxillofacial to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a computed tomography (CT) scan of the maxillofacial to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) rendered 
on September 22, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should not have been partially denied. The 
Plan denied your request. The Plan says this is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to 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 polymerase chain reaction for the diagnosis of onychomycosis is experimental/ investigational. 
There is insufficient scientific evidence in the current medical literature to indicate that this technology is as 
beneficial as the established alternatives. 
 
 
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 a fungal infection polymerase chain reaction (PCR) rendered on September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for the U-Step II mobility stabilizer. We decided that the Plan does not 
have to pay for the associated shipping charges.  
 
You asked the Plan to pay for the U-Step II mobility stabilizer and associated shipping charges you received on 
October 26, 2022.. You say that you had to purchase this item from the manufacturer because it was not 
available in your local area. The Plan says that the provider billed this service incorrectly. 
 
 
 We decided that the Plan has to pay for the U-Step II mobility stabilizer.  
 
Medicare rules state that Plans are responsible for providing enough documentation to us to support their 
denials.  In this case, the Plans sole rationale for denial is that the provider billed this service incorrectly.  
This argument is not persuasive. First of all, the provider didnt bill for this item- this was a direct patient 
reimbursement request, so there were no codes submitted by the provider for payment.  It appears that the Plan 
just assigned code E1399 to this item without doing any research.  A simple online search of the 
manufacturers website clearly shows that the appropriate code for the U-Step II mobility stabilizer is E0147.  
The Plan could have easily ascertained this information by doing this basic research.  Further, the Plan has 
made no argument or assertion that the enrollee does not meet coverage criteria for this item.  As a result, we 
can only assume that all other coverage criteria have been met.  The burden is on the Plan to show that its 
denial is correct. Because the Plan had the ability to determine the allowable amount for the U-Step II and 
failed to do so, we find that the Plan failed to meet this burden. Therefore, we find that the Plan has to pay for 
the U-Step II mobility stabilizer you purchased.  
 
We also decided that the Plan does not have to pay for the associated shipping charges. 
 
The Plan follows Medicare rules. Medicare rules say that there is no Medicare payment for shipping or delivery 
of durable medical equipment.  We cannot obligate the Plan to pay for the associated shipping charges for this 
item because Medicare does not cover shipping or delivery under any circumstances. Therefore, we decided 
that the Plan does not have to pay for the associated shipping charges. 
 
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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the requested LTACH services are not medically 
necessary. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The health 
plan has approved ongoing care in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast. 
 
You asked the Plan to pre-approve breast MRI. You say that the enrollee has personal history of breast cancer. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for this test. 
 
The Plan follows Medicare rules. Medicare rules state that breast MRIs are only covered under certain 
conditions. 
 
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 breast MRI. Our reviewer says that the 
enrollee does not meet criteria for this test. Our physician reviewer found there are no mammogram or 
ultrasound reports in the records and the notes indicate the enrollee is due for screening mammography in July 2023. There is no documentation of genetic predilection of breast cancer using the Gail or Tyrer-Cuzick risk 
models. The medical necessity of breast MRI has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of breast MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the breast.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 device. 
 
You asked the Plan to pre-approve a Life2000 device. 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 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 Life2000 device. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the Life2000 device is not 
medically necessary. The enrollee has severe chronic obstructive pulmonary disease (COPD), and already has a 
trilogy home ventilator. The Life2000 device is not a true ventilator, because it is not capable of providing full 
ventilatory support. Its primary intended use is during activity, and not to treat chronic carbon dioxide (CO2) 
retention during sleep. There is inadequate evidence of the safety and effectiveness of this device in the treatment of COPD. 
 
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 Life2000 device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Life2000 device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99152) provided on September 2, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed services. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patients level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not show the 
presence of a trained observer. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia 
services (99152) provided on September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99401 billed for date of service February 1, 
2022. 
 
You asked the Plan to pay for procedure code 99401. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 99401 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99401 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99401 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99401 billed for date of service February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes E2609-NU-GA and E2617-NU-GA provided on June 
27, 2022. 
 
You asked the Plan to pay for codes E2609-NU-GA and E2617-NU-GA. You say that you are looking for a 
denial so that you can bill the patient's secondary insurance. The Plan denied your request. The Plan says codes 
submitted with the GA modifier are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted with the GA modifier will be 
denied as not reasonable and necessary. You billed the items in dispute with a GA modifier, so no payment 
may be made for these codes under the Medicare program.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes E2609-NU-GA and E2617-NU-GA have not been met. Therefore, we decided that the Plan 
does not have to pay for codes E2609-NU-GA and E2617-NU-GA provided on June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator (AED) vest (K0606) 
provided on July 29, 2021. 
 
You asked the Plan to pay for the AED vest. You say that this item was medically necessary. The Plan denied 
your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the AED vest was not filed until November 30, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the automatic external defibrillator (AED) vest (K0606) provided on July 29, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee meets FDA indications 
for use. The Plan denied your request. The Plan says the Intracept procedure is not the appropriate procedure 
for the enrollee at the current time. 
 The Plan follows 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 Intracept procedure. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found that the Intracept procedure is 
experimental for back pain. More research is needed to demonstrate its safety and efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 
30, 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 November 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met.  Specifically, the acupuncture services in this case were not requested on the basis of a diagnosis for chronic 
low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatments.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 
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 November 24, 
2022.