Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic accessories (L5999, L5781, L5964, L5828, 
L5845, L5850, L5856, L5848, L5925, L5968) 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says a standard socket has been approved. 
 
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 the accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found these items exceed the enrollee's medical needs as the documentation is inconsistent if the 
enrollee is at a K3 level. The documentation indicates a history of myelomalacia which can cause balance 
issues, severe spinal stenosis with back pain, joint pain and that the enrollee owns a powered wheelchair and 
regular wheelchair as well as needing a cane if ambulating for a long period of time or at risk of falling without 
a cane. Additionally, the provider notes that the enrollee is relatively homebound. The documentation does not 
support that the enrollee's functional level and activities requires a microprocessor knee over a mechanical knee 
and advanced foot over a regular foot. The L5999 BOA Click Socket exceeds the enrollee's medical needs, and 
is not proven safe and effective. The L5871 exceeds the enrollee's medical needs, and is not proven superior to 
a standard socket. The L5964 exceeds the enrollee's medical needs, and is not medically necessary, as the 
documentation does not support that the enrollee requires this protection against unusually harsh environmental 
situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is 
afforded by a standard cover. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve prosthetic accessories (L5999, L5781, L5964, L5828, L5845, L5850, L5856, L5848, 
L5925, L5968)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
October 31, 2020, to November 5, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says payment of DRG 435 is not supported, as a review supports DRG 436.  
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 435 (MALIGNANCY OF 
HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC). 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 services at issue in this case were not supported by 
the medical records. Our physician reviewer found the enrollee was admitted and treated for rectal bleed and 
diarrhea in the setting of history of partial colectomy for colon cancer one year prior, but had refused 
chemotherapy. He was treated with IV antibiotics for possible sepsis. However, there was insufficient support 
made for the DRG 435 as the documentation does not show sepsis criteria met. There was no evidence of organ 
dysfunction due to infection. Vitals were stable and responded to initial treatments, fluids. Therefore, DRG 436 
is more appropriate based on the provided documentation.  
 
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 to the enrollee from October 31, 2020, to November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0364) provided by a participating 
provider on November 24, 2021. 
 
You asked the Plan to pay for a cone beam CT capture. You say that you could not eat on that side of your 
mouth. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says 
D0364 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam CT capture (D0364) provided by a participating provider on November 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan you had on November 5, 
2021. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that you believe the Plan should at 
least share in the cost of this procedure. The Plan denied your request. The Plan says you were charged this 
copayment correctly. The Plan says that because the allowed amount for this service ($108.09) is less than your 
copayment obligation, you are responsible for the full allowed amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $110 copayment for the duplex scan. The duplex scan falls within the Medicare-
covered radiological diagnostic services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the duplex scan you had on November 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on August 23, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is insufficient documentation to corroborate the 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, we have confirmed that code 76942 
is a column II code to column I code 62322. 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 ultrasound services provided to the enrollee on August 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
February 21, 2021, to March 2, 2021. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says the DRG 
was updated.  
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 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 services at issue in this case were not supported by the medical records. 
Our physician reviewer found the enrollee was admitted and treated for urinary tract infection. However, the 
notes do not describe organ dysfunction related to an exaggerated immune response from the infection being 
system to meet Sepsis 3 criteria. Kidney function quickly improved following IV fluid administration. 
Therefore, the provided documentation does not sufficiently support the DRG 871. The DRG 689 would, 
therefore, be more appropriate, according to the provided documentation.  
 
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 to the enrollee from February 21, 2021, to March 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (G0151, Q5001) provided to the 
enrollee from September 15, 2021 to October 8, 2021. 
 
You asked the Plan to pay for home health services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, a RAP was 
not submitted within 5 days of the start of care. Therefore, we decided that the Plan does not have to pay for the 
home health services (G0151, Q5001) provided to the enrollee from September 15, 2021 to October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical items and services billed with codes S1015 and 
S8301 for date of service September 20, 2021. 
 
You asked the Plan to pay for codes S1015 and S8301. You say that you provide these items at your expense 
and you deserve to be paid for them. The Plan denied your request. The Plan says these codes are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that that codes that have a status indicator of 'I' in the 
Medicare Physician Fee Schedule Database are not valid for Medicare purposes.  Medicare uses another code 
for reporting of, and payment for, these services. Both code S1015 and S8301 have a status indicator of 'I'. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes S1015 and S8301 have not been met. Therefore, we decided that the Plan does not have to 
pay for medical items and services billed with codes S1015 and S8301 for date of service September 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (99232) provided October 16, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says a correct claim is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 
 We find that CPT code 99232 is not supported in the medical record. Specifically, the claim was billed without 
a required modifier. Based on this information, we decided that Medicare rules for coverage of the outpatient 
services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient services 
(99232) provided October 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care (99356) provided June 25, 2021. 
 You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceed the allowed amount. 
 
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 99356 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient 
care (99356) provided June 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from October 19, 2021, to October 21, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you went in for a colonoscopy that 
resulted in abnormal findings. The Plan denied your request. The Plan says the self-administered drugs are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also says the self-administered drugs are not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting from October 19, 2021, to October 21, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology rendered on September 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 PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 surgical pathology 
rendered on September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) provided 
September 8, 2021. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the item was medically necessary. 
The Plan denied your request. The Plan says coverage rules were not met. 
 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 did not 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 continuous glucose 
monitor have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose 
monitor (K0553, K0554) provided September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
March 14, 2019, to March 25, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the DRG adjustment was appropriate.  
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 377 (HEMORRHAGE WITH MCC). 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 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
enrollee had dementia and presented to the Emergency Department (ED) with periodic confusion and delirium 
found to have anemia on workup, chronic related to iron-deficiency anemia. There was no signs of an active 
hemorrhage or perforation related to the gastric ulcer to support gastric ulcer with hemorrhage as a diagnosis 
for this admission. The records do not sufficiently support the DRG of 377. DRG 384 is more appropriate 
according to the provided documentation.  
 
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 to the enrollee from March 14, 2019, to March 25, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment of these services. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
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 provided on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on January 17, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 36558 is "Insertion of tunneled centrally inserted central 
venous catheter, without subcutaneous port or pump; age 5 years or older." 
 
We find that CPT code 36558 is not supported in the medical record. Specifically, this code was billed within 
the global period for the surgery that was rendered on January 14, 2021. 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 surgical services provided to the enrollee on January 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that 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 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 at the current level of function, the enrollee needs a physical therapy and 
occupational therapy routine. The enrollee's rehabilitation can be safely provided at a lower intensity and alternate setting in a skilled nursing facility. Documentation does not support the necessity for admission to an 
IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for clinical psychology services provided on November 5, 2021. 
 
You asked the Plan to pay for the clinical psychology services. You say that these services were provided in 
good faith and were medically necessary. The Plan denied your request. The Plan says the medical record 
documentation for these services does not meet Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for a clinical psychologist to be paid by 
Medicare, the medical records have to include certain information. Specifically, the record must show either 
that the patient's primary care or attending physician referred the patient to the clinical psychologist, or the 
patient must formally consent to the consultation. The medical record must state the date the patient consented 
to the consultation or the manner of notification to the physician. In this case, the medical record is silent on 
any referral from the patient's treating physician and there is no mention of the enrollee's consent to the 
consultation or the patient's choice to decline the physician consultation. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the clinical psychology services have not been met. Therefore, we decided that the Plan does not 
have to pay for clinical psychology services provided on November 5, 2021.