Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of non-tunneled centrally inserted central 
venous catheter services coded 36556 provided on February 21, 2022. 
 
You asked the Plan to pay for the insertion of non-tunneled centrally inserted central venous catheter services. 
You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services 
billed 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 36556 is insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. 
 
 We find that CPT code 36556 is not supported in the medical record. Specifically, the documentation shows 
that these services were planned, but the records do not include supporting documentation to show that they 
were actually performed. Based on this information, we decided that Medicare rules for coverage of the 
insertion of non-tunneled centrally inserted central venous catheter services have not been met. Therefore, we 
decided that the Plan does not have to pay for the insertion of non-tunneled centrally inserted central venous 
catheter services coded 36556 provided on February 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. 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 76641 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 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service June 8, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this service was medically necessary. The 
Plan denied your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service June 8, 2022, billed with 
code 99153.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 25, 2021, 
to November 27, 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 original determination to remove principal diagnosis (PDX) code A41.89 Other specified sepsis thereby changing the diagnosis related group (DRG) from 871 to 190 for dates of service November 25, 
2021, through November 27, 2021. The Plan denied your request. The Plan says the removal of the diagnosis 
codes and change in DRG is based on lack of supporting clinical evidence from the medical record provided 
and not based solely on coding guidelines. 
 
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 A41.89 Other specified sepsis. 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 physician reviewer found there was no clinical or laboratory evidence of sepsis. The review has 
determined that the principal diagnosis (PDX) code A41.89 Other specified sepsis is not supported.  
 
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 November 25, 2021, to November 27, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 92523, 92610, 97110, 97116, 97161, 97530 and 
97535. We decided that the Plan does not have to pay for procedure code 97166.  
 
You asked the Plan to pay for therapy services (97166, 92523, 92610, 97110, 97116, 97161, 97530 and 97535) 
provided from May 6, 2022, to May 20, 2022. You say that this claim was billed appropriately. The Plan says 
that claim line 15 (procedure code 97166) was billed without the necessary GO modifier. This claim is denied 
as it was not billed in accordance with Medicare billing guidelines. In addition, due to this error this claim is 
considered incomplete and therefore no part of this claim is processable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that certain therapy codes must be reported with the GN, GO, or GP modifier to distinguish the 
discipline of the plan of care under which the service is delivered. The rules also say that a claim may be 
returned to the provider for correction if there is required information which is invalid or incomplete. 
 
We decided that the Plan has to pay for procedure codes 92523, 92610, 97110, 97116, 97161, 97530 and 
97535.  
 
We looked at the file and Medicare rules. The Plan denied this claim as a whole on the basis that a single claim 
line is missing a modifier. Although a modifier may be necessary to process any specific claim line, it is not 
considered required information in this scenario. Required information is defined as any data element that is 
needed in order to process a claim, specifically, Provider Name or Date of Service. A claim could not be 
processed if required information, such as to whom payment should be made, who received services or the date 
they were performed, were absent. This claim is submitted under the Physician Fee Schedule and includes the 
required information to process this claim. It is not appropriate to deny this claim as a whole due to a single 
claim line error. Based on this information, we have determined that the rules for billing these services have 
been met. Therefore, we decided that the Plan has to pay for procedure codes 92523, 92610, 97110, 97116, 
97161, 97530 and 97535.  
 
We also decided that the Plan does not have to pay for procedure code 97166. 
 
We looked at the file and Medicare rules. Code 97166 was submitted without modifier GN, GO, or GP, 
although this code is among those which require one of these modifiers. Based on this information, we have 
determined that the rules for coverage of code 97166 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 97166. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 3, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that it is felt that there is no 
contract which indicates that lab testing is included in payment for the dialysis services. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 3, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Krystexxa (J2507). 
 
You asked the Plan to pre-approve Krystexxa. You say that the requested drug is necessary for the enrollee. 
The Plan denied your request. The Plan says the requested drug is 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 Krystexxa. Our reviewer says that the 
requested drug, Krystexxa, is not medically necessary. Our physician reviewer found the medical records 
provided and the Medicare-approved major drug compendia there is no documentation that the Krystexxa at 
issue in this case meets all Medicare criteria for medically reasonable and necessary. The reviewer found that 
the provided records do not document the enrollee has been evaluated for glucose-6-phosphate dehydrogenase 
(G6PD) deficiency which is a contraindication to use of Krystexxa due to the risk of hemolysis and 
methemoglobinemia. Therefore, the reviewer found that the requested use of Krystexxa is not medically 
reasonable and 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 Krystexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Krystexxa (J2507).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 24, 2020, 
to February 23, 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 the 
provider submitted supporting documentation for reconsideration of DRG adjustment. The Plan denied your request. The Plan says they changed the DRG from 981 to 982 due to removal of the secondary diagnosis code 
for cerebral edema (G93). 
 
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 G93-cerebral edema. 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 
physician reviewer found there was no clinical evidence of cerebral edema, and the enrollee received no 
treatment for this condition. The review has determined that the records did not support that G93.6- cerebral 
edema is appropriate for the hospital stay.  
 
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 December 24, 2020, to February 23, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for a lipid panel. We decided that the Plan does not 
have to waive the copayment for a metabolic panel.  
 
You asked the Plan to waive the copayment for a lipid panel provided on August 16, 2022. You say that you 
only had one test done and you do not have control over where the test gets sent to be read. The Plan says that 
this cost sharing was charged correctly. 
 
 
 We decided that the Plan has to reduce the copayment for a lipid panel.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductible, and coinsurance). Your contract with the Plan says that you must pay $10 copayment 
per day for covered lab tests other than FIT tests. You were already asked to pay $8.46 copayment for a 
metabolic panel provided on August 16, 2022. Therefore, you can only be asked to pay $1.54 copayment for 
the lipid panel because these amounts total the $10 per day copayment. 
 
The Plan has asked you to pay $10 copayment for lipid panel in addition to the $8.46 copayment you have 
already been asked to pay. Based on the Plan contract, however, you cannot be asked to pay more than $1.54 
copayment for the lipid panel because this results in a total copayment of $10 for lab tests on August 16, 2022. 
Therefore, we decided that the Plan has to reduce the copayment amount for a lipid panel from $10 to $1.54.  
 
We also decided that the Plan does not have to waive the copayment for the lipid panel. 
 
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 $10 per 
day for other Medicare-covered laboratory tests that are not FIT tests. You have already been asked to pay 
$8.46 for lab tests on this date of service. Therefore, you are responsible for $1.54 copayment because this 
amount results in the total $10 per day copayment for August 16, 2022. 
 
Therefore, we decided that the Plan does not have to waive the copayment for a lipid panel. 
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for upper gastrointestinal endoscopic 
procedures (00732-QY) provided on November 15, 2021. 
 
You asked the Plan to pay for the anesthesia service. You say that this should be covered. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 12, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia for 
upper gastrointestinal endoscopic procedures (00732-QY) provided on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service September 
19, 2022. 
 
You asked the Plan to pay for procedure code 74176. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 74176 is bundled into payment for code 74177. 
 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 74176 
is a column II code to column I code 74177. 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 74176 billed for date of service September 19, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an additional 12 
physical therapy visits are not medically necessary. 
 
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 physical therapy. 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 the enrollee does not require the unique skills of a professional 
therapist to provide treatment safely and effectively. The services can be safely and effectively performed only 
by a therapist, or by or under the supervision of a therapist.  The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design, or deliver a program to maintain the enrollee's current condition or to prevent or slow 
further deterioration. The enrollee has had instruction in a home exercise program and can transition to an 
independent home exercise program.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 12 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service February 21, 
2022. 
 
You asked the Plan to pay for procedure code G0453. The Plan denied your request. The Plan says payment for 
code G0453 is bundled into payment for code 51785.  
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 G0453 
is a column II code to column I code 51785. 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 G0453 billed for date of service February 21, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 2 standard, single power 
option, captain's chair, patient weight capacity up to and including 300 pounds (K0836) and wheelchair 
accessories (E2603, E0955, E1028x2, E1002, E2361x2). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet medical necessity as defined by Medicare for these specialty features. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has osteoarthritis and weakness.  The record provided indicates the enrollee has an 
abnormal but normal lower extremity strength. The record does not indicate that this mobility deficit impairs 
the enrollee's participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, 
grooming and bathing in customary locations within the home. The record does not indicate that the deficit 
cannot be able to be ameliorated by a walker, cane or manual wheelchair. The elements of the coverage criteria 
are not satisfied. 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 2 standard, single power option, captain's 
chair, patient weight capacity up to and including 300 pounds (K0836) and wheelchair accessories (E2603, 
E0955, E1028x2, E1002, E2361x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 6, 2022 to August 10, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on March 6, 2022 to August 10, 2022, by 
an out-of-network (OON) provider.