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

 We decided that the Plan does not have to pay for inpatient hospital services provided on June 15, 2021, to 
June 28, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the DRG 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 provided with diagnosis codes N17.0 and E43. 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 submitted records do not support the billing of diagnosis codes N17.0 and E43. Our 
physician reviewer found acute tubular necrosis (ATN) is not supported. The criteria for ATN include 
urinalysis with evidence of decreased osmolality, muddy urinalysis with diagnostic renal cells and casts 
evident, and low urine output.Low urine output is not documented and no urinalysis was performed. There is a 
presumptive diagnosis due to change in creatinine but actual ATN is not established. The criteria for severe 
malnutrition are not met as the enrollee did not have weight loss or evidence of decreased food intake. He did 
have low weight but the criteria require evidence of recent weight loss. The reduced muscle mass asserted in 
the dietitians note is not measured.  
 
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 on June 15, 2021, to June 28, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion subcutaneous cardiac rhythm monitor 
including programming (33285). 
 
You asked the Plan to pre-approve cardiac loop recorder. You say that it was recommended by the cardiologist 
to have a loop recorder placement. The procedure was denied due to not having a Holter monitor but the 
enrollee did. The Plan denied your request. The Plan says the records do not support that this request is 
reasonable and necessary. 
 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 cardiac loop recorder. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the device implantation is not medically necessary at this time. The enrollee already 
has the diagnosis of atrial fibrillation and has no history of cardiac syncope. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac loop recorder have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the insertion subcutaneous cardiac rhythm monitor including programming 
(33285).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) and core buildups (D2950) for 3 teeth. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary for the enrollee due to extreme wear of the teeth. The Plan denied your request. The Plan says your 
benefit for the requested items or services has already been exhausted.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollee's benefit for the requested items or services was exhausted on the date of approval of March 
20, 2023. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) and core buildups 
(D2950) for 3 teeth.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 23, 2022, billed with 
codes 81314, 81321, 81351, 81479. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes, 
the laboratory shall report only one unit of service of one code. The file shows that a comprehensive cancer panel was provided. We looked at the file and Medicare rules. This 
was an NGS panel that was not billed with a single panel code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the genetic testing provided on May 23, 2022, billed with codes 81314, 
81321, 81351, 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87631 billed for date of service May 31, 
2022. 
 
You asked the Plan to pay for procedure code 87631. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says code 87631 is not supported in the medical record. 
 
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 87631 is infectious agent detection by nucleic acid; 
respiratory virus, includes multiplex reverse transcription, when performed, and multiplex amplified probe 
technique, multiple types or subtypes, 3-5 targets. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 87631. Our reviewer says that CPT code 
87631 is not supported in the medical record. Our reviewer found the number of targets tested in this case is not 
in the range of the code selected. There is a more specific code for the number of targets included in this test. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87631 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87631 billed for date of service May 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional outpatient occupational therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee is stable to continue 
rehabilitation with a home exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found Strength training is not a skilled service. Your pain has reduced 
sufficiently to continue to perform the effective exercises at home. You have a chronic condition and will need 
to continue a home exercise program as unique input from a skilled therapist is not medically 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 7 additional outpatient occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) 
provided on October 17, 2022. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service 
provided has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service January 11, 2022. Specifically, 
the Plan provides coverage for one limited oral evaluation per year. You previously received this service on 
January 11, 2022, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this 
service. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation-problem 
focused (D0140) provided on October 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy with biopsy provided on November 21, 2022. 
 
You asked the Plan to pay for a colonoscopy with biopsy. You say that you would like the denial of this service 
to be reconsidered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a colonoscopy with 
biopsy provided on November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 core buildups, including any pins when required 
(D2950 x11).  

You asked the Plan to pre-approve the core buildups. You say that the enrollee is in need of immediate 
treatment. The Plan denied your request. The Plan says core buildup is not a covered expense under the 
enrollee's dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pre-approve 11 
core buildups, including any pins when required (D2950 x11).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99283-25 and 13152 billed for September 
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 procedure codes 99283-25 and 13152 are not supported. 
 
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 99283 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and low level 
of medical decision making. The definition of code 13152 is repair, complex, eyelids, nose, ears and/or lips; 2.6 
cm to 7.5 cm. 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for these services. Our reviewer says that procedure codes 
99283-25 and 13152 are not supported. Our reviewer found the records do not document an expanded problem-
focused history, an expanded problem-focused examination, and medical decision making of moderate 
complexity to support code 99283. 
 
The records describe a layered closure but do not document a complex repair requiring scar revision, 
debridement, extensive undermining, stents, or retention sutures. Code 13152 is therefore not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99283-25 and 13152 billed for September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300), power 
standing feature (E2301), and chest support hardware (E1028). 
 
You asked the Plan to pre-approve the power seat elevation feature, power standing feature, and chest support 
hardware. You say that the items are medically necessary. The Plan denied your request. The Plan says a power seat elevation feature and power standing feature are non-covered because they are not primarily medical in 
nature and the chest strap hardware was requested for the power standing feature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the power seat elevation feature (E2300), power standing 
feature (E2301), and chest support hardware (E1028).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 88360. The Plan denied your request. The Plan says payment for 
code 88360 is bundled into payment for code 88321.  
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 88360 
is a column II code to column I code 88321. 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 88360 billed for date of service June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the ambulatory infusion pump (code E0781) billed for date of service 
July 27, 2022. 
 
You asked the Plan to pay for code E0781. You say that this item was needed for the patient's chemotherapy 
treatment. The Plan denied your request. The Plan says that you did not append the KX modifier as is required. 
 
The Plan must follow Medicare rules. Medicare rules say that or all claims for external insulin infusion pumps 
(E0784) and insulin (J1817), a KX modifier should be added to the HCPCS code. The rule that was in effect on 
the date of service in this case does NOT specify that code E0781 requires the KX modifier.  It appears that the 
Plan is basing its denial on the Local Coverage Article that is currently in effect.  The current article does 
require the use of the KX modifier for all external infusion pumps.  However, that rule was not in effect on the 
date of service and is therefore not controlling in this case.  The Plan has supplied no other argument in support 
of its denial.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0781 have been met. Therefore, we decided that the Plan has to pay for the ambulatory 
infusion pump (code E0781) billed for date of service July 27, 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 pre-approve the removal of left breast implant 
 You asked the Plan to pre-approve the surgical procedure. You say that you are requesting that the denial of 
coverage for the left breast be re-reviewed and overturned for coverage. The Plan denied your request. The 
Plan says the removal of the left breast implant does not meet the criteria of LCD L37020. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
reviewer found in this case the records does not indicate that the enrollee has a condition enumerated in the 
rules for which coverage is available. The elements of the coverage criteria are not satisfied, and the requested 
service is not recommended. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the removal of left breast implant
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the pain management (0117U) provided on September 19, 2022. 
 
You asked the Plan to pay for the pain management. You say that you would like this claim to be reviewed and 
reprocessed for prompt payment. The Plan denied your request. The Plan says that this procedure 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. The record does not show whether the physician who ordered this service is in-
network, or out-of-network with the Plan. It is the burden of the Health Plan to substantiate their denial with 
evidence. 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 the pain management (0117U) provided on September 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 partial colectomy (44140) and reduction of volvulus 
(44050) provided on May 24, 2022. 
 
You asked the Plan to pay for the partial colectomy (44140) and reduction of volvulus (44050). You say that 
supporting documentation was submitted and the records should be reviewed. The Plan denied your request. 
The Plan says procedure codes 44140 and 44050 are not supported by the medical records submitted. 
 
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 44140 is colectomy, partial; with anastomosis. The CPT 
Code Manual definition of code 44050 is reduction of volvulus, intussusception, internal hernia, by 
laparotomy. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the partial colectomy (44140) and reduction of volvulus 
(44050). Our reviewer says that the services do not meet the criteria for coverage. Our reviewer found the 
operative report does not include enough information to confirm a partial colectomy with anastomosis was 
performed. In addition, the procedure report does not include enough information to confirm a reduction of 
volvulus has been performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the partial colectomy (44140) and reduction of volvulus (44050) have not been 
met. Therefore, we decided that the Plan does not have to pay for the partial colectomy (44140) and reduction 
of volvulus (44050) provided on May 24, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Herceptin Hylecta. 
 You asked the Plan to pre-approve Herceptin Hylecta. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Herceptin Hylecta. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found biologics Kanjinti or Trazimera 
would be as effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Herceptin Hylecta have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Herceptin Hylecta.