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

 
We decided that the Plan does not have to pay for the lab services (85014, 85018, 85049, 85025) provided on 
September 3, 2020. 
 
You asked the Plan to pay for the lab services. You say that this claim was submitted late due to circumstances 
outside of your control. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until August 23, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the lab services (85014, 85018, 85049, 85025) provided on September 3, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan billed with code 70450 
for October 19, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for the computed tomography (CT) scan billed with code 70450 for October 19, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room (ER) services billed with code 99285 for July 29, 
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 that the provider type is not able to bill this code. 
 
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 code 99285 is not payable to the billing provider type; 
however, the file shows that the provider is an Emergency Medicine physician. There is no documentation to 
support that the code is not payable as billed. Therefore, we decided that the Plan has to pay for the emergency 
room (ER) services billed with code 99285 for July 29, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG); recording in coma or sleep 
only provided to the enrollee on June 9, 2022. 
 
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 Current Procedural Terminology (CPT) code 95822-26 remains 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 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep only." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case a two channel EEG 
was performed using leads form the somatosensory evoked potentials (SSEP) modality. According to the 
established technical standards from the adult clinical nurse specialist (ACNS), the minimum number of 
channels needed for an EEG is 8. In this case, the services billed for do not satisfy the minimal technical standards for provision of this procedure. In as much it cannot be said that this service is/was supported by the 
records. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for electroencephalogram (EEG); recording in coma or sleep only provided to the enrollee on June 
9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) March 17, 2022, to 
April 16, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with this denial, and 
you believe these services were medically necessary and the medical records do support the use. The Plan 
denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep 
vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) March 17, 2022, to April 16, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for percutaneous image-guided injection, drainage or 
aspiration procedures on the spine or spinal cord; lumbar or sacral (code 01938) provided on July 26, 2022. 
 
You asked the Plan to pay for anesthesia for percutaneous image-guided injection, drainage or aspiration 
procedures on the spine or spinal cord; lumbar or sacral. You say that the claim was billed with the correct 
code. The Plan denied your request. The Plan says that that this service does not meet the coverage 
requirements in the applicable Local Coverage Determination (LCD) or National Coverage Determination 
(NCD). Related services performed in connection with the denied procedure are also 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. Specifically, the Plan has not provided the Medicare rule used to substantiate 
their denial. Therefore, we decided that the Plan has to pay for anesthesia for percutaneous image-guided 
injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral (code 01938) provided 
on July 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that full payment should be made for this claim. 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, for 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 September 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 17, 2021, to 
April 20, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says diagnosis code 
A41.50 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis A41.50, defined as gram-
negative sepsis, unspecified. 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 diagnosis A41.50 is not supported by 
documentation. Our physician reviewer found the enrollee has a history of chronic obstructive pulmonary 
disease (COPD), hypertension, diabetes mellitus, and obstructive sleep apnea who was brought to emergency 
department by ambulance. She was treated with supplemental oxygen and given intravenous fluids and 
antibiotics. She was admitted and received insulin for glycemic control. Her condition improved, and she was 
discharged home. As there was no evidence of sepsis, the documentation does not support the diagnosis.  
 
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 April 17, 2021, to April 20, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG); recording in coma or sleep 
only provided to the enrollee on March 8, 2022. 
 
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 a more appropriate code for the service billed. 
 
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 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep only." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the technical report does indicate 
that an EEG was performed. However, this code is not supported as the enrollee was not in a coma or sleep. 
There are more appropriate codes to use in this clinical scenario. (e.g., 95812 and 95813). Therefore, the 
records do not support that CPT 95822: Electroencephalogram (EEG); recording in coma or sleep only was rendered in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for electroencephalogram (EEG); recording in coma or sleep only provided to the enrollee on 
March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intermittent limb compression device. 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that this item is medically 
necessary. The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pre-approve intermittent limb compression 
device. Our reviewer says that this item is not medically necessary. Our physician reviewer found the member 
does not have a diagnosis of lymphedema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve intermittent limb compression device.
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 you are unable to care for yourself if you go home. 
The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care provided on May 21, 2022. 
 
You asked the Plan to pay for the initial hospital care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says unauthorized, out-of-network care is not covered. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 initial hospital care. Our reviewer says 
that the records do not indicate that the care provided was emergent. Our physician reviewer found the enrollee 
presented to the ED with fever, chills, cough, and shortness of breath. There was no sign of sickle cell crisis or 
other acute condition that would require emergent 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 the initial hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for initial hospital care provided on May 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility services provided on April 13, 2022, by 
an out-of-network (OON) provider. 
 
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 rendered by a non-contracted provider without prior authorization. 
 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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility services provided on April 13, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-segmented pneumatic compressor (E0650) segmental 
gradient pressure pneumatic appliance, half leg (E0673) non-segmental pneumatic appliance for use with 
pneumatic compressor, half leg (E0666) and Orthotic(s) management and training (97760) provided January 8, 
2022 to January 27, 2022. 
 You asked the Plan to pay for a pneumatic compression device and appliances. You say that you request 
reconsideration of the claim with the requested medical information. The Plan denied your request. The Plan 
says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that a PCD that provides 
intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a 
preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not 
eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, a Pneumatic Compression Device (PCD) that provides 
intermittent limb compression for the purpose of prevention of venous thromboembolism (which should be 
billed as E0676) and is a preventive service. This item is not a covered benefit of Medicare or the Plan. PCDs 
are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, 
regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for 
non-segmented pneumatic compressor (E0650) segmental gradient pressure pneumatic appliance, half leg 
(E0673) non-segmental pneumatic appliance for use with pneumatic compressor, half leg (E0666) and 
Orthotic(s) management and training (97760) provided January 8, 2022 to January 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 19340 and 15860 billed for date of service 
January 18, 2022. 
 
You asked the Plan to pay for procedure codes 19340 and 15860. You say that you disagree with the denial. 
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 codes 19340 and 15860 is 1. The MAI value for this code is 2. You billed 2 
units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 19340 and 15860 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 19340 and 15860 billed for date of service January 18, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for percutaneous image-guided injection, drainage or 
aspiration procedures on the spine or spinal cord; lumbar or sacral (code 01938) provided on July 15, 2022. 
 
You asked the Plan to pay for anesthesia for percutaneous image-guided injection, drainage or aspiration 
procedures on the spine or spinal cord; lumbar or sacral. You say that this code was billed correctly. The Plan 
denied your request. The Plan says that this service does not meet the coverage requirements in the applicable 
Local Coverage Determination (LCD) or National Coverage Determination (NCD). Related services performed 
in connection with the denied procedure are also 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. Specifically, the Plan has not provided the Medicare rule used to substantiate 
their denial. Therefore, we decided that the Plan has to pay for anesthesia for percutaneous image-guided 
injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral (code 01938) provided 
on July 15, 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.