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

 
We decided that the Plan does not have to pay for the creatinine and pH testing performed along with urine 
drug testing on April 28, 2022. 
 
You asked the Plan to pay for the testing at issue. You say that this claim should be paid in full. The Plan 
denied your request. The Plan says the codes billed are not separately payable with drug testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing at issue have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for the creatinine and pH testing performed along with urine drug testing on April 28, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an onlay porcelain/ceramic four or more surfaces. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs this restoration to return 
function and structural stability to her dental piece. The Plan denied your request. The Plan says this service is 
not a covered benefit under your dental 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
onlay porcelain/ceramic four or more surfaces.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that your medical condition would improve 
from LTACH services. The Plan denied your request. The Plan says the Long-Term Acute Care Hospital 
(LTACH) services you and/or your provider are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you are unstable and require short-term additional acute care services that can 
safely be administered at the current facility until your condition becomes more stable and appropriate for a 
lower level of care. At this time, you do not require the services of an LTACH and completion of treatment at 
the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 18, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, 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 the lab services provided on May 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography study (95811). 
 
You asked the Plan to pre-approve a polysomnography. You say that the requested service is a medical 
necessity for you. 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 a polysomnography. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that you have an established diagnosis of obstructive sleep apnea (OSA) and have a CPAP 
device that is 7 years old. There is no device download in the case record to assess compliance and effectiveness of the device. There is no detailed sleep-symptoms history or Epworth sleepiness score. There 
have not been any major changes in health status or body weight. 
 
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 polysomnography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a polysomnography study (95811).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 8, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service July 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 7, 2022, to 
February 10, 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 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 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 that diagnosis code billed. Our 
physician reviewer found the enrollee presented to the emergency department via emergency medical services 
with the inability to catch their breath. There was insufficient clinical evidence in the documentation to validate 
A41.9 (Sepsis, unspecified organism). In addition, the documentation in the medical record indicates that the 
enrollee was discharged to home with home health. Therefore, the services are not payable as billed.  
 
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 7, 2022, to February 10, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496.  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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service August 9, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for codes 92928, 93459, 99152, and 99232 billed for date of service 
December 6, 2021. 
 
You asked the Plan to pay for codes 92928, 93459, 99152, and 99232. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says that for codes 92928 and 99152, the 
Plan states that the documents do not support the services billed.  For codes 93459 and 99232, the Plan denied 
these stating 'unbundling of services.' 
 
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's vague denial rationales are simply based on an edit that 
was applied to the claim.  The Plan has provided absolutely no explanation as to how it concluded that for 
codes 92928 and 99152, the documents do not support the services billed, or that codes 93459 and 99232 
should be bundled. First, in relation to codes 92928 and 99152, the Plan has failed to specify why the 
documents provided do not support these codes.  The Plan has not provided any analysis or explanation as to 
why the records provided do not substantiate the service.  Second, in relation to the codes denied for 'bundling', 
the Plan has failed to identify what, if any, codes are primary, resulting in the bundling issue.  The burden is on 
the Plan to support is denial.  The Plan has failed to provide any analysis to support its denial in the limited 
case file it provided to us. Therefore, we decided that the Plan has to pay for codes 92928, 93459, 99152, and 
99232 billed for date of service December 6, 2021.  
 
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 pay for inpatient hospital services provided on February 16, 2022, to 
February 21, 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 you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the DRG billed 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 J96.01, defined as acute respiratory failure 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 documentation does not support the secondary diagnosis 
billed. Our physician reviewer found the enrollee presented to the emergency department with dyspnea and 
hypoxia at providers office. In the emergency department, the enrollee had a SpO2 of 87% with ambulation and 
91% with rest on room air. The enrollee required two liters per minute supplemental oxygen initially and was 
weaned to one liter per minute by hospital day two. There was no clinical or laboratory evidence of acute 
respiratory failure with hypoxia. The documentation does not support the secondary diagnosis code J96.01, 
(acute respiratory failure with hypoxia) in the documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 16, 2022, to February 21, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation that the enrollee 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J0604 billed for date of service January 3, 
2022 to January 31, 2022. 
 
You asked the Plan to pay for procedure code J0604. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is 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 CPT code. 
 
We find that CPT code J0604 is not supported in the medical record. Specifically, J0604 is bundled in payment 
to the ESRD facility. Based on this information, we decided that Medicare rules for coverage of procedure code 
J0604 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code J0604 
billed for date of service January 3, 2022 to January 31, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on May 10, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this claim denied as inpatient. You also say 
that the enrollee came from their residence. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from June 2, 2021, to October
13, 2021.
You asked the Plan to pay for the dental services. You say that you needed emergency dental care. The Plan
denied your request. The Plan says this provider has opted out of Medicare and is not eligible for payment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental
services provided from June 2, 2021, to October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service September 
22, 2021. 
 You asked the Plan to pay for procedure code 99292. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 99292 is bundled into 
payment for code 92950. 
 
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 99292 
is a column II code to column I code 92950. 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 99292 billed for date of service September 22, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36416 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for procedure code 36416. You say that you believe this claim should be 
reprocessed. The Plan denied your request. The Plan says procedure code 36416 is 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 code 36416 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36416 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36416 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36416 billed for date of service August 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93978 billed for date of service March 22, 2022. 
 
You asked the Plan to pay for code 93978. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says payment for code 93978 is bundled into payment for 
code 93975.  
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 93978 
is a column II code to column I code 93975 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 code 93978 billed for date of service March 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bivigam.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that IVIG is covered when specific criteria are met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has unspecified demyelination disorder. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The criteria for coverage are not met and the Bigivam is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Bivigam.