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

 
We decided that the Plan does not have to pay for lab services provided on July 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral surgery services (D9243, 96372, D9239) provided 
August 15, 2022. 
 
You asked the Plan to pay for the oral surgery services. You say that these services were medically necessary 
and should be fully covered. The Plan denied your request. The Plan says the codes billed are not eligible for 
payment. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. The Coding Policy Manual 
also explains what is referred to as Column One/Column Two Correct Coding and Mutually Exclusive Edits. These are code pairs that should not be reported together. 
 
The codes D9243 and D9239 involve the care, treatment, filling, removal or replacement of your teeth or the 
structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. 
Code 96372 shares a column I / column II bundled relationship with code 41116 which was also billed, and 
therefore cannot be paid separately. Therefore, we decided that the Plan does not have to pay for oral surgery 
services (D9243, 96372, D9239) provided August 15, 2022.
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 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. 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 11, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the cost share for x-ray provided on May 2, 2022. 
 
You asked the Plan to waive the cost share for x-ray. You say that you feel you should only pay your x-ray 
copay of $0. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay $25 copayment for emergency care.  
 
The Plan says you must pay $75 copayment for x-ray. Based on the Plan contract, however, you cannot be 
asked to pay more than $25 copayment for x-ray. Therefore, we decided that the Plan has to waive the cost 
share for x-ray provided on May 2, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 an Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the magnetic resonance imaging (MRI) scan dated June 2, 2022, did not demonstrate 
Modic type changes at all of the requested levels. Additionally, there are multiple plausible pathologic sources 
of significant pain generation. The enrollee's presentation is non-specific to any pathologic entities. 
Documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. The 
available documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves 
as being medically necessary and/or reasonable at this time. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on April 26, 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 procedure codes 01630 and 64415 are not covered. 
 
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 01630 is anesthesia for open or surgical arthroscopic 
procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not 
otherwise specified. 
 
We find that CPT code 01630 is not supported in the medical record. Specifically, the records do not support 
the number of units billed, as the records document 109 minutes of anesthesia time.  
 
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 64415 
is a column II code to column I code 01630. 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. 
 
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 anesthesia services rendered on April 26, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Estrace cream. 
 
You asked the Plan to pre-approve Estrace. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Estrace 
cream.  
 Benefits for Estrace 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service May 23, 
2022. 
 
You asked the Plan to pay for procedure code 11721. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 11721 is bundled into payment for code 11055.  
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 24, 2022, to 
January 25, 2022, 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 it is felt 
that this claim was billed at the correct DRG. The Plan denied your request. The Plan says diagnosis code 
J96.91 is not supported which changes the appropriate DRG. 
 
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 J96.91, defined as 
Respiratory failure, unspecified with hypoxia. 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 reported secondary 
diagnosis J96.91 is not supported. Our physician reviewer found in this case, there was no clinical or laboratory 
evidence of acute respiratory failure with hypoxia. The review has determined that the documentation did not 
support diagnosis code J96.91.  
 
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 January 24, 2022, to January 25, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays rendered on August 10, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were billed incorrectly. 
 
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 x-rays rendered on August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 17, 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 for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier was reported. 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 laboratory services rendered on 
February 17, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve additional applications of a skin substitute graft. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that only two more applications can be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the wound care providers write that the enrollees wound clearly benefitted from applications of 
EpiFix skin substitute. Since the applications were stopped, the rate of healing has plateaued. There is fear that 
without expedient resumption of the skin substitute, the wound will decline, and the healing that was 
accomplished will be lost. The documentation supports that continued use of EpiFix skin substitute is 
medically reasonable and necessary for the enrollee in this case. The enrollees wound healing has plateaued, 
placing her at risk for potentially life-threatening complications. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve additional applications of a skin substitute graft.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 51785, 95861, and 95870 for services provided on July 
13, 2022. 
 
You asked the Plan to pay for codes 51785, 95861, and 95870. 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. 
 
We find that CPT codes 51785, 95861, and 95870 are not supported in the medical record. Specifically, the 
technical report did not include documentation of needle electromyography studies (EMG) of the anal or 
urethral sphincter, using any technique; therefore, code 51785 cannot be verified. 
 The technical report did not include documentation of needle electromyography, for 2 extremities with or 
without related paraspinal areas; therefore, code 95861 cannot be verified. 
 
The technical report did not include documentation of a needle electromyography, for a limited study of 
muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, 
cranial nerve supplied muscles, or sphincters; therefore, code 95870 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of codes 51785, 95861, and 95870 
have not been met. Therefore, we decided that the Plan does not have to pay for codes 51785, 95861, and 
95870 for services provided on July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. 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. 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4314, & A4357 billed for date of service 
February 16, 2022. 
 
You asked the Plan to pay for procedure codes A4314, & A4357. You say that this service was medically 
necessary. The Plan denied your request. The Plan says procedure codes A4314, & A4357 are considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure codes A4314, & A4357 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes A4314, & A4357 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes A4314, & A4357 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes A4314, & A4357 billed for date of service 
February 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 23, 2022, to 
February 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be paid. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 23, 2022, to 
February 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CPAP supplies. 
 
You asked the Plan to pre-approve CPAP supplies. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says there is a lack of information provided to determine what 
CPAP supplies are needed and medical records to support criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of CPAP supplies have been met. In this 
case, you and your provider have not provided enough information to determine if you meet medical necessity 
criteria. Please speak with your treating/ordering provider to determine what CPAP supplies are needed with 
corresponding current procedural terminology (CPT) codes. Please also speak with your treating/ordering 
provider about medical records supporting Medicare criteria for the requested supplies. These should be provided to the Plan for a new authorization request. Therefore, we decided that the Plan does not have to pre-
approve CPAP supplies.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 70450 billed for date of service August 10, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says that the payment for code 70450 is included in the 
payment for code 70496. 
 
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 forwarded any claim information or other 
documentation to show that a conflicting service (70496) has been billed for the enrollee on this same date. 
Therefore, we decided that the Plan has to pay for procedure code 70450 billed for date of service August 10, 
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.