Persius/hicric huggingface dataset:
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 12, 
2022. 
 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 12, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 28, 2022, billed 
with codes 37252, 37253, 37184, and 76942. 
 
You asked the Plan to pay for the medical services as billed. You say that the billed services are medically 
necessary and billed correctly. The Plan denied your request. The Plan says the records do not support that the 
billed services were rendered. 
 
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 37184 is Primary percutaneous transluminal mechanical 
thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance 
and intraprocedural pharmacological thrombolytic injection(s); initial vessel. Code 37252 is defined as 
intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to 
code for primary procedure). Code 37253 is defined as Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; 
each additional noncoronary vessel (List separately in addition to code for primary procedure). CPT code 
76942 is defined as Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or 
therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary 
vessel (List separately in addition to code for primary procedure). 
 
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 medical services as billed. Our reviewer says that the 
billed services are not supported by the records provided. Our reviewer found in regard to CPT code 37184, the 
procedure report does not include enough documentation to confirm this procedure has been performed per 
NCCI Policy Manual. Procedure report documents "Catheter directed thrombectomy was performed of the AT 
to restore flow".  In this case, the procedure does not match the description of 37184 and cannot be verified. 
For 37252 and 37253, the report does not include documentation to confirm the findings of Intravascular 
ultrasound and therefore, these procedures cannot be verified. For 76942, the report does not have sufficient 
documentation to support that this was 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 medical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on January 28, 2022, billed with codes 37252, 
37253, 37184, and 76942.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from November 1, 2021, through 
February 8, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that there are no psychiatrists accepting patients in the 
East Hawaii area and you were seeking therapy for the passing of your late husband. The Plan denied your 
request. The Plan says Medicare/Medicare Advantage (MA) plans do not recognize mental health counselors as 
eligible providers. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided from November 1, 2021, through 
February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on November 29, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on November 29, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient psychiatric admission and services from 
February 17, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that this care is necessary and court-
ordered. The Plan denied your request. The Plan says the inpatient psychiatric stay is not medically necessary 
by Medicare criteria, and the enrollee could be treated in a lesser restrictive setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 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 inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet Medicare criteria for psychiatric care at an acute inpatient level. Our 
physician reviewer found that the enrollee was involuntarily admitted to the state hospital acute inpatient 
psychiatric hospitalization on February 17, 2022, with Schizophrenia Spectrum Disorder (Paranoid). Based 
upon review the records provided, it was not expected this enrollee would improve in a reasonable period of 
time as he did not have dangerousness to self or others, auditory or visual hallucinations and was not showing 
any behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at 
the acute inpatient level of care rather than a lower level of care. It did not appear that active treatment was 
taking place. It did not appear that the services were reasonably expected to improve the enrollees condition or 
for the purpose of diagnosis. Based upon review, the records provided for the admission of this enrollee do not 
meet criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to 
himself or others and was without auditory or visual hallucinations. He is noted to be cooperative and 
compliant with treatment while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient psychiatric admission and services from February 17, 2022, 
forward.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services rendered on October 14, 2021. 
 
You asked the Plan to pay for these services. You say that the services were rendered in good faith. The Plan 
denied your request. The Plan says the services are not covered. 
 
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 these services 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 the psychotherapy services rendered on October 
14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from December 31, 2020, 
through January 2, 2021, at DRG 157. 
 
You asked the Plan to pay for the inpatient services at DRG 157. You say that two of the six criteria were met 
and documented in the medical record, thus supporting the diagnosis of malnutrition per current guidelines. 
You say that the code assignment is valid since there is reasonable support for the diagnosis and the denial 
should be overturned. The Plan denied your request. The Plan says the determination to remove diagnosis code 
E43 is upheld. 
 
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 secondary diagnosis code E43, defined as 
unspecified severe protein calorie malnutrition. 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 services at DRG 157. Our reviewer says that the documentation does not support the secondary 
diagnosis code E43. Our physician reviewer found that severe malnutrition was documented as related to lack 
of meaningful oral intake secondary to pain from mouth ulcer. While the physician documented the diagnosis 
of severe malnutrition, the medical records do not sufficiently support this condition as being present at the 
time of this encounter.  
 
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 the inpatient services provided from December 31, 2020, through January 2, 2021, at DRG 157.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control, electronic connection between 
wheelchair controller and two or more power seating system motors, an expandable controller, harness, calf 
support, and safety belt. 
 
You asked the Plan to pre-approve an attendant control, electronic connection between wheelchair controller 
and two or more power seating system motors, an expandable controller, harness, calf support, and safety belt. 
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 power wheelchair accessories are covered when 
specific criteria are met. 
 
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 an attendant control, electronic 
connection between wheelchair controller and two or more power seating system motors, an expandable 
controller, harness, calf support, and safety belt. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found based on the medical records provided there is no documentation that 
you meet the coverage criteria detailed in the Local Coverage Article: Wheelchair Options/Accessories - Policy 
Article - A52504 for the requested accessories. The E2311 electronic connection, E2377 expandable controller 
and E2313 harness are not covered as provided records document that you have 4+/5 upper extremity strength 
and are independent with eating and grooming thus indicating you have adequate upper extremity strength and 
function to operate the wheelchairs power options with their own switches. The E2331 attendant control is not 
covered in addition to a beneficiary-operated drive control. The K0108 calf support kit and E0978 seatbelt are 
not covered as they are unbundled charges. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an attendant control, electronic connection between wheelchair controller and 
two or more power seating system motors, an expandable controller, harness, calf support, and safety belt have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an attendant control, electronic connection between wheelchair controller and two or more power seating system motors, an expandable 
controller, harness, calf support, and safety belt.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided from December 6, 2021, through 
January 8, 2022. 
 
You asked the Plan to pay for infrared therapy. The Plan denied your request. The Plan says the claim does not 
meet criteria for approval due to service not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for infrared therapy provided from December 6, 2021, through 
January 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the abutment supported 
porcelain/ceramic crown (D6058) provided January 20, 2022. 
 
You asked the Plan to provide additional payment for the abutment supported crown. You say that this service 
was provided in January of the new plan year. The Plan denied your request. The Plan says your full $2,000 
benefit was applied to the service provided January 20, 2022. 
 
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. The Plan covers the abutment 
supported crown up to a $2,000 annual supplemental dental allowance. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that your full $2,000 annual supplemental dental allowance was applied to the services received on January 20, 2022. Therefore, we 
decided that the Plan does not have to provide additional payment for the abutment supported 
porcelain/ceramic crown (D6058) provided January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 7, 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 September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve stimulator. 
 
You asked the Plan to pre-approve a nerve stimulator. 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 no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 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 nerve stimulator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Therefore, you do not meet the coverage criteria detailed in the LCD. 
 
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 nerve stimulator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a nerve stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, 83789, G0480) provided May 20, 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 
(80307, 83789, G0480) provided May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 27, 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 July 27, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on January 27, 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 that procedure code 81455 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 Plan states that procedure code 81455 is non-covered; however, the 
referenced Local Coverage Determination (LCD) L35160 and Local Coverage Article (LCA) A57526 do not 
explicitly state that the code is not covered. The Plan has not provided any binding Medicare rules or 
documentation to support that the services are not payable as billed. Therefore, we decided that the Plan has to 
pay for the laboratory services rendered on January 27, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transport services provided on  
January 20, 2022. 
 
You asked the Plan to pay for non-emergency transport service. You say that that the member could not be 
discharged home unless she was transported professionally, or she would have had to stay the night in the 
emergency room. The Plan denied your request. The Plan says prior authorization is required for non-
emergency transportation. 
 
The Plan contract covers ambulance services. The Plan says that prior authorization is required for non-
emergency transportation. 
 
We looked at the file and the Plans rules. The file shows that prior authorization is required for non-emergency 
transportation. Based on this information, we decided that the Plans rules for coverage of non-emergency 
transport service have not been met. Therefore, we decided that the Plan does not have to pay for non-
emergency transport services provided on January 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on December 17, 2021. You asked the Plan to pay for physical therapy services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
The Plan contract covers outpatient rehabilitation services. The Plan says prior authorization may be required. 
 
We looked at the file and the Plans rules. The file shows that prior authorization was not obtained. Based on 
this information, we decided that the Plans rules for coverage of physical therapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided on  
December 17, 2021.