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

 
We decided that the Plan does not have to pay for drug testing services (G0843) provided on March 7, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and were ordered by the 
enrollee's treating physician. The Plan denied your request. The Plan says these services cannot be verified as 
medically necessary as the physician order is largely illegible. 
 
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 drug testing have been met. 
Specifically, the record shows that multiple attempts were made to obtain a legible copy of the physician order 
for these services. Based on the documents submitted, it appears that a category labelled miscellaneous was 
checked and indicated for testing, but if any specific drugs or drug categories are included in the indicated 
category they cannot be read. Without this information, we cannot verify that the services provided were 
requested by the enrollees treating physician, and therefore we cannot verify the medical necessity of these 
services. Therefore, we decided that the Plan does not have to pay for drug testing services (G0843) provided 
on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the consultation (D9310) and excision of benign lesion 
(D7410) provided on October 7, 2021. 
 
You asked the Plan to pay for the consultation and excision of benign lesion. You say that you would like to 
appeal these services. The Plan denied your request. The Plan says that the consultation and excision of benign 
lesion will not be paid for by the Plan. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the consultation and excision of benign lesion by a contract provider. The file does not 
show that the Plan provided notice that the consultation and excision of benign lesion would not be covered. 
Because you were referred for this medical service by a Plan doctor, the Plan must hold you harmless for the 
services provided. Under Medicare rules, this means the consultation and excision of benign lesion is 
considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the 
consultation (D9310) and excision of benign lesion (D7410) provided on October 7, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4657 billed for date of service June 2, 
2021, to June 30, 2021. 
 You asked the Plan to pay for procedure code A4657. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for code A4657 is 0. The MAI value for this code is 2. You billed 9 units of this code, 
exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 
A4657 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code A4657 
billed for date of service June 2, 2021, to June 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) psychotherapy, 60 minutes 
with patient when performed with an evaluation and management service (List separately in addition to the 
code for primary procedure) (90838) provided April 5, 2022 to April 12, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that you are requesting payment for 
psychotherapy services you received. The Plan denied your request. The Plan says proof of payment required. 
Receipt or proof of payment that shows you paid for the services on the claim form submitted is needed. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the outpatient office visit (99213) 
psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List 
separately in addition to the code for primary procedure) (90838) provided April 5, 2022 to April 12, 2022. 
have been met. The Plan made multiple attempts to obtain proof of payment from the enrollee without success. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99213) psychotherapy, 
60 minutes with patient when performed with an evaluation and management service (List separately in 
addition to the code for primary procedure) (90838) provided April 5, 2022 to April 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional mileage for routine transportation. 
 
You asked the Plan to pre-approve the additional mileage. You say that the additional mileage is necessary. 
The Plan denied your request. The Plan says the request exceeds your benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. The mileage from your home to the providers office avoiding tolls is a total of 97 which is 47 miles over your allowed benefit. The mileage from 
your home to the providers office not avoiding tolls, highways and ferries is a total of 97 which is 47 miles 
over your allowed benefit. Therefore, we decided that the Plan does not have to pre-approve the additional 
mileage for routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 1, 2021 to 
February 9, 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 submitted records do not support the 
billing of primary diagnosis code N17.0. 
 
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 primary diagnosis code N17.0. 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 primary diagnosis code N17.0. Our 
physician reviewer found the records support an admission for chronic kidney disease stage IIIB. Even though 
acute tubular necrosis (ATN) is documented, the enrollee was without clear and consistent provider 
documentation support or clinical indicators 
related to the findings of acute kidney injury due to ATN. He had a baseline creatinine of 1.2-1.6 and his 
creatinine was 2.14 upon admission. There is no evidence of laboratory abnormalities consistent with a 
diagnosis of ATN.  
 
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 February 1, 2021 to February 9, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 9, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent or declination date to consultations, and the date of consultations in the patients medical record. There 
was no documentation of contact in the patient record. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on March 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs daily physician visits, 24-hour 
rehab nursing care and intensive PT/OT. The Plan denied your request. The Plan says the request is not 
medically necessary; the enrollee can safely receive the services they need 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. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of 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 IRF admission and services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services (99309) provided on January 26, 
2022. 
 
You asked the Plan to pay for SNF care. You say that this claim was denied as a duplicate in error and should 
be paid. The Plan denied your request. The Plan says that this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the Plan did not provide any evidence 
such as a copy of a check or a provider remittance to show that payment has actually been provided for this 
service. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. 
Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services (99309) provided on 
January 26, 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta injections. 
 
You asked the Plan to pre-approve Zilretta injections. You say that the requested Zilretta injections are 
medically necessary. The Plan denied your request. The Plan says that the requested Zilretta injections are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Zilretta injections. Our reviewer says 
that the requested Zilretta injections are medically necessary. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of osteoarthritis of the knee. The requested drug is being used for its current 
Food and Drug labelled indication. The Food and Drug Administration has not restricted its use to a single 
time. The elements of the coverage criteria are satisfied. The requested service is 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 Zilretta injections have been met. Therefore, we decided that the Plan has to 
pre-approve Zilretta injections.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service May 17, 
2022. 
 You asked the Plan to pay for procedure code 76642. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 2. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service May 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that without the coverage, your health and wellbeing 
will decline, and your quality of life will be endangered. The Plan denied your request. The Plan says the 
request is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tangential biopsy of skin (11102) provided on May 13, 
2022. 
 
You asked the Plan to pay for the surgical service. You say that this should be paid. The Plan denied your 
request. The Plan says the service is not covered when performed by a provider that is not enrolled in 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical service have not been met. Therefore, we decided that the Plan does not have to pay 
for the tangential biopsy of skin (11102) provided on May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73521 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code 73521. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 73521 is bundled into payment for code 73522. 
 
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 73521 is a column II code to column I code 73522. 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 73521 billed for date of service May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair and accessories (E1161, E2231, 
E2204, E2213x2, E2211x2, K0053x2, K0040x2, E0951x2, E0973x2, E0971, E2609, E2617, E0955, E1028). 
 
You asked the Plan to pre-approve a manual wheelchair and accessories. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the Medicare DME benefit does not cover DME in a 
skilled nursing facility, therefore a manual wheelchair is never covered at member's present location. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a manual wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair and accessories (E1161, 
E2231, E2204, E2213x2, E2211x2, K0053x2, K0040x2, E0951x2, E0973x2, E0971, E2609, E2617, E0955, 
E1028).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554) supply allowance used with a therapeutic CGM device 
(K0553). 
 
You asked the Plan to pre-approve the Freestyle Libre 14 day. You say that your fingers and hands are black 
and blue from manual blood glucose checks. The CGM would allow you to stay off insulin as it would alert 
you to blood sugar highs and lows. The Plan denied your request. The Plan says the Freestyle Libre 14 Day is 
not medically necessary as the enrollee is not on any intensive insulin regimen. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Freestyle Libre 14 day have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554) supply allowance used with a therapeutic CGM device 
(K0553).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service December 
21, 2021. 
 
You asked the Plan to pay for procedure code 99601. 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 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service December 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortic ultrasound rendered on April 12, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 the abdominal aortic 
ultrasound rendered on April 12, 2022.