Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from November 4, 2022, 
to December 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 the itemized bill charges and claim charges do not match. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the services have been met. The 
itemized bill charges ($673,487.54) and the UB-04 charges ($670,786.54) do not match in this case. Despite 
multiple requests from the plan, clarification or a corrected claim have not been received. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital services rendered from November 4, 2022, to 
December 9, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 95940. We decided that the Plan does not have to pay 
for procedure codes 95861, 95868, 95937, 95938 and 95939.  
 
You asked the Plan to pay for procedure codes 95861, 95868, 95937, 95938, 95939 and 95940 billed for date 
of service January 24, 2023. You say that you have billed the services at issue correctly. The Plan says that 
rules for payment have not been met. 
 
We decided that the Plan has to pay for procedure code 95940.  
 
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 for payment for procedure code 95940. Specifically, the Plans denial indicates 
that code 95940 has a Professional/Technical indicator of 1. We find that code 95940 has an indicator of 0. 
This means that the code describes physician services. The code has been billed without a modifier, which is 
correct since physician services cannot be split into professional and technical components. Code 95940 has 
been reported correctly. It is the Plans responsibility to support its denial with evidence. In this case, the Plans 
denial of code 95940 is not supported, so we must find in your favor. Therefore, we decided that the Plan has to 
pay for procedure code 95940.  
 
We also decided that the Plan does not have to pay for procedure codes 95861, 95868, 95937, 95938 and 
95939. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95861, 95868, 95937, 
95938 and 95939. This means there is both a professional and technical component for the CPT code(s). In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 
95861, 95868, 95937, 95938 and 95939. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 95861, 95868, 95937, 95938 and 95939 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 95861, 95868, 95937, 95938 and 95939. 
 
  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that without the requested therapy, this enrollee 
is at high risk for hospital readmission and potentially life-threatening exacerbations. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for approval of a ventilator. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and chronic 
respiratory failure. The enrollee's documentation does not support the need for home ventilator. The enrollee 
does not have documented failure of BIPAP. She tolerated and improved with BIPAP therapy, hence, no 
indication for home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 3, 2023, to July 31, 
2023, billed with procedure code 90999. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim has not been billed with the required 
value code. 
 
The Plan must follow Medicare rules. Medicare rules say that a Value code D5 is required on all ESRD claims, 
even if no reading was performed.  
 We looked at the file and Medicare rules. The claim has not been reported with the required D5 code. Based on 
this information, we decided that Medicare rules for coverage of the practitioner services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on July 3, 
2023, to July 31, 2023, billed with procedure code 90999.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 25, 2022, 
to September 28, 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 the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 I21.A1, described as 
myocardial infarction type 2. 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 documentation does not support the billed 
code. Our physician reviewer found that there was insufficient support for the code, I21.A1 as the enrollee did 
not exhibit any cardiac-specific symptoms not attributable to other causes or had electrocardiogram (ECG) 
changes suggestive of infarction. Myocardial injury was present, but not infarction, according to the records.   
 
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 September 25, 2022, to September 28, 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs services provided in 
an LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care 
and is currently unstable for transfer to an LTACH. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The review has determined that the requested LTACH services are not medically necessary or 
reasonable. At the time of the request for LTACH services, the enrollee has a persistent right pleural effusion 
and has had periods of hypotension and tachycardia. The enrollee does not require services at the LTACH that 
are not available at the acute care hospital where he is currently receiving care. The requested LTACH services 
are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and 
able to be furnished safely and effectively only on an inpatient basis. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on June 29, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that the supply allowance was 
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the supply allowance for a CGM. Our 
reviewer says that the supply allowance for a CGM coverage criteria was not met. Our physician reviewer 
found that although the enrollee meets the medical necessity criteria for a CGM, there is requirement that the 
enrollee be seen every 6 months while using the CGM. This enrollee does not appear to have been seen since 
October of 2022, so the CGM supplies ordered in June of 2023 do not meet the provided medical necessity 
criteria for continued coverage. 
 
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 supply allowance for a CGM have not been met. Therefore, we decided that 
the Plan does not have to pay for the supply allowance for a continuous glucose monitor (CGM) provided by an 
out-of-network provider on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental and investigational. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity of implantation of the wireless pulmonary 
artery pressure monitoring system (CardioMEMS) for management of congestive heart failure (CHF) in this 
patient. There remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 CDx testing (0242U) provided May 26, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that the enrollee was diagnosed with an advanced 
solid cancer. The diagnosis from Guardant360 CDx enabled the doctor to determine the optimal treatment 
pathway for their patient.  The Plan denied your request. The Plan says that this testing is not medically 
necessary. 
 
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 pay for the genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of stage IIIA non-small cell lung cancer status post resection in 
August 2022. Additional treatment included 4 cycles of chemotherapy followed by surveillance. In May 2023, 
the enrollee underwent computed tomography (CT) scan of the chest, abdomen and pelvis which showed 
enhancing mass lesion in posterior chest wall consistent with chest wall metastasis / recurrence. There was no 
convincing evidence of metastasis in the abdomen or pelvis. Positron emission tomography (PET)/CT and 
magnetic resonance imaging (MRI) of brain for re-staging as well as interventional radiology referral for CT 
guided biopsy chest lesion were planned and Guardant360 CDx was ordered. All of the criteria have been met. 
 
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 genetic testing have been met. Therefore, we decided that the Plan has to 
pay for the Guardant360 CDx testing (0242U) provided May 26, 2023.  
 
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 rendered from September 5, 2022, 
to November 4, 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 a corrected claim was not submitted to the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the services have been met. The 
charges on the itemized bill ($1,437,342.14) and the UB-04 ($1,436.302.14) do not match. Despite multiple 
attempts by the plan, a corrected claim or clarification of the discrepancy has not been received.. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital services rendered from September 5, 2022, to 
November 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PuraPly AM, per sq cm (Q4196) and Affinity, per sq cm 
(Q4159). 
 
You asked the Plan to pre-approve PuraPly AM and Affinity. 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 follows Medicare rules. Medicare rules say that for all wounds, documentation (as outlined in the 
documentation requirements of the policy) and a comprehensive treatment plan, before initiation of a 
specialized wound therapy product is required. 
 
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 PuraPly AM and Affinity. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the current literature lists skin 
substitutes after MOHS surgery as not reasonable or necessary. Also, only one skin substitute product at a time 
is reasonable, whereas there was no documented explanation for using more than one at once. Therefore, this request for skin substitutes will be considered not 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 PuraPly AM and Affinity have not been met. Therefore, we decided that the 
Plan does not have to pre-approve PuraPly AM, per sq cm (Q4196) and Affinity, per sq cm (Q4159).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) performed on April 
3, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the provided records do not document that the medical necessity criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRAs are covered only when they are 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 pay for the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the history 
was "family history of brain aneurysm, which if true in a first degree relative is a valid indication for the test. 
However, no clinical notes have been included in the submitted records to determine what the family history is. 
Without such documentation the medical necessity of the MRA of the brain cannot be determined. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for magnetic resonance angiography (MRA) performed on April 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show suicidal or homicidal thoughts. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 not medically reasonable or necessary. Our physician reviewer found that it did not 
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care 
rather than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance 
including delusions, auditory or visual hallucinations. The enrollee was not showing behavioral issues. The 
enrollee was cooperative and compliant. The health plans denial of inpatient psychiatric services appears 
appropriate. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to an inpatient psychiatric facility.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 10160 and 99307 billed for date of service 
July 18, 2023. 
 
You asked the Plan to pay for procedure codes 10160 and 99307. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the services at issue was not 
billed with the required modifiers to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The services at issue are within the global surgery period of code 
10160 provided on July 11, 2023. We find that the services at issue may be unrelated to the surgical procedure; 
however, the required modifiers to indicate this were not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 10160 and 99307 
billed for date of service July 18, 2023.