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

 
We decided that the Plan does not have to pay for codes 64445 and 64447 provided on September 26, 2022. 
 
You asked the Plan to pay for codes 64445 and 64447. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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 
 
We find that CPT codes 64445 and 64447 are not supported in the medical record. Specifically, an anatomical 
modifier was not appended to these codes on the claim. These services are not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of codes 64445 and 64447 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 64445 and 64447 provided on September 
26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 24, 2021, to 
September 22, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for episodes may be submitted prior to the 
60th day if the beneficiary has been discharged and treatment goals have been met, though payment will not be 
pro-rated unless more home health care is subsequently billed in the same 60-day period. 
 We looked at the file and Medicare rules. The file shows that there was not a 60 day gap between the services 
at issue and the enrollee's previous home health period of care. 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 home health services rendered from August 24, 2021, to September 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 16, 2022, to 
February 24, 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 these 
services and diagnoses were reported correctly and are supported as billed. The Plan denied your request. The 
Plan says the DRG submitted on this claim is not supported in the medical record. 
 
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 sepsis, unspecified organism (A41.9) and severe 
sepsis without septic shock (R65.20). 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 these diagnoses are not 
supported in the medical record. Our physician reviewer found that there was no clinical or laboratory evidence 
of sepsis in this case. There was no documentation of persistent hypotension. While the appeal letter mentions 
labile blood pressures, there were no noted mean arterial pressure (MAP) less than 70. An initial creatinine 
level of 1.36 is noted in the presence of chronic kidney disease (CKD). However, the enrollees creatinine level 
decreased to within normal limits following intravenous fluid hydration. The repeat creatine level was 1.18. 
The enrollee had adequate urine volumes noted on the days with a Foley catheter. When foley was removed, 
the enrollee was incontinent, and urine was unable to be measured. Leukocytosis noted in the presence of a 
known infection. The urine culture was positive for Escherichia Coli and Proteus Mirabilis. The review has 
determined that the documentation did not support sepsis, unspecified organism (A41.9) and severe sepsis 
without septic shock (R65.20).  
 
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 February 16, 2022, to February 24, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230), a 
crown (D2740), a prefabricated post and core (D2954), endodontic therapy (D3320), and an extraction (D7210) 
for tooth #2 and #29 provided on September 22, 2022, October 7, 2022, and November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the dental services should not have 
been declined. The Plan denied your request. The Plan says your benefit for the intraoral radiographic images 
has already been exhausted. Also, the denial of payment for the crown, prefabricated post and core, endodontic 
therapy, and the extraction is correct, because they are not covered by the Plan. 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, certain limitations apply. The record 
shows your benefit for the intraoral radiographic images was exhausted on the date of service of September 22, 
2022. The crown, prefabricated post and core, endodontic therapy, and the extraction are not covered under the 
Plans dental benefit. Therefore, we decided that the Plan does not have to pay for the intraoral radiographic 
images (D0220 and D0230), a crown (D2740), a prefabricated post and core (D2954), endodontic therapy 
(D3320), and an extraction (D7210) for tooth #2 and #29 provided on September 22, 2022, October 7, 2022, 
and November 21, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 87481 and 87653. We decided that the Plan does not 
have to pay for procedure codes 87641-91, 87798-91, and 87150-91.  
 
You asked the Plan to pay for the lab testing services provided on June 27, 2022.. The Plan says that the codes 
are included in code 87500. 
 
We decided that the Plan has to pay for procedure codes 87481 and 87653.  
 
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 codes 87481 and 87653 are supported in the medical records. The codes do not have a PTP code 
edit with code 87500. Based on this information, we decided that the Medicare rules for coverage have been 
met. Therefore, we decided that the Plan has to pay for procedure codes 87481 and 87653 provided on June 27, 
2022.  
 
We also decided that the Plan does not have to pay for procedure codes 87641-91, 87798-91, and 87150-
91. 
 
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 the codes, billed with modifier 91 are not supported. Specifically, the records do not show that 
repeat procedures were provided. Based on this information, we decided that the Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87641-91, 
87798-91, and 87150-91 provided on June 27, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an admission to Calvary Hospital Inc.. 
 
 
You asked the Plan to pre-approve an admission to Calvary Hospital Inc. You say that the enrollee's needs 
cannot be met in a lower level of care. The enrollee requires specialty acute care at an end-of-life facility. The 
Plan denied your request. The Plan says the records do not show that the enrollee needs acute inpatient hospital 
services that could not be met in the current hospital. 
 
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 admission to Calvary Hospital Inc. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the proposed transfer will not result in clinical services being provided that 
are materially different than those available in the planned palliative care setting. The documentation does not 
support that the enrollee in this case requires services that are not available in the setting where she is currently 
receiving 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 an admission to Calvary Hospital Inc. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an admission to Calvary Hospital Inc..
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95866, 95909) provided on September 12, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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 95886 is "Needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure)". The CPT Code Manual definition of code 95909 is 
"Nerve conduction studies; 5-6 studies". 
 
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 use of codes 95886 
and 95909 is not supported by the records provided. Our reviewer found that the record does not contain evidence that needle electromyography with nerve conduction, amplitude and latency/velocity study was 
performed on five or more muscles. The record states that intraoperative monitoring was performed with 
needles stimulating some of the muscles. There is a more specific code for this procedure. The record does not 
support that nerve conduction tests with stimulation, recording, and ground electrode placement were 
performed with placement individualized for the patient's anatomy, with 5-6 studies being performed. The 
record states that intraoperative neuromonitoring was performed with needle stimulation. There is a more 
specific code for this procedure. 
 
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 the services (95866, 95909) provided on September 12, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda (pembrolizumab) 100MG/4ML solution (J9271). 
 
You asked the Plan to pre-approve the medication. You say that this is needed for treatment. The Plan denied 
your request. The Plan says that the medication is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found pembrolizumab has meaningful clinical activity in undifferentiated pleomorphic sarcoma (UPS) and 
differentiated/de-differentiated liposarcoma (LPS). 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve Keytruda (pembrolizumab) 100MG/4ML solution (J9271).  
 
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 pre-approve negative pressure wound therapy. 
 
You asked the Plan to pre-approve negative pressure wound therapy. You say that the records provided support 
the need for the requested treatment. The Plan denied your request. The Plan says the services in dispute are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that negative pressure wound therapy is covered for 
certain medical indications. 
 
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 negative pressure wound therapy. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is a 
47-year-old male with a Stage IV pressure wound on the left buttock that has not responded to use of a wound 
vacuum for 4 weeks. There is no documentation of a complete wound therapy program has been tried or 
considered and ruled out prior to application of negative pressure wound therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of negative pressure wound therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve negative pressure wound therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 30, 2022. 
 
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 March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (A4520, A4554, A6250). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested incontinence supplies are not covered by Medicare or the 
Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (A4520, 
A4554, A6250).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute, a roll-a-bout, lower leg platform, 
with or without wheels (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that you disagree with the denial. The Plan 
denied your request. The Plan says there is insufficient published clinical literature demonstrating safety and 
effectiveness in the Medicare population to establish the medical necessity for these products. Platform crutch 
(also called a roll-a-bout) is not covered, comfort or convenience item, not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The requested crutch substitute is listed as a non-covered item with Medicare and the Plan. The item at issue in 
this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general 
public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does 
not have to pre-approve a crutch substitute, a roll-a-bout, lower leg platform, with or without wheels (E0118).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
26, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly and should be 
paid. 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 for the HCPCS/CPT code will be denied. 
 
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. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
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 November 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 18, 2021, 
to November 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 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 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 A41.9, defined as sepsis, unspecified organism. 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 documentation does not support the DRG billed. Our physician 
reviewer found the enrollee presented to the emergency department for evaluation of cough, shortness of breath 
and diarrhea. The enrollee demonstrated tachycardia and lab studies revealed that platelets remained above 
150,000 per microliter and Total bilirubin remained below 1.20 mg/dL through the hospital stay. An elevated 
creatinine of 1.25 mg/dL was noted on presentation, however, creatinine improved to 1.11 mg/dL after IV fluid 
treatment in the emergency department. Furthermore, the documentation reflects that the enrollee was hypoxic 
with oxygen saturation in the 80's and with partial pressure of oxygen arterial of 51 on room air, however, the 
enrollee has a history of chronic obstructive pulmonary disease (COPD) in need of home oxygen due to 
inability to maintain saturations over 90% on room air due to COPD and was discharge with oxygen at 3L at 
rest and 4L with exertion. In this case, there was no clinical or laboratory evidence of sepsis. Therefore, the 
DRG billed 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 18, 2021, to November 23, 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 procedure code 78832 billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for procedure code 78832. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 78832 is bundled into payment for code 79101. 
 
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 78832 
is a column II code to column I code 79101 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 78832 billed for date of service August 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 12, 2022, 
to March 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. 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 February 12, 2022, to 
March 13, 2022.