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

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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. 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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, the enrollee does not meet the criteria for November 11, 2023 forward as this enrollee 
was not shown to be a danger to herself or others There were no delusions, auditory or visual hallucinations 
noted. She was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the practitioner services provided on July 20, 2023, to July 
23, 2023. 
 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 payment for these services is bundled into 
payment of the inpatient stay. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic services provided to a Medicare 
beneficiary by a hospital (or an entity wholly owned or wholly operated by the hospital) on the date of the 
beneficiary's inpatient admission or during the 3 calendar days immediately preceding the date of admission are 
required to be included on the Part A bill for the inpatient stay. 
 
We looked at the file and Medicare rules. The outpatient services in question fall within 3 days of the inpatient 
admission. 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 the practitioner 
services provided on July 20, 2023, to July 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784) provided on July 28, 2023. 
 
You asked the Plan to pay for polycarbonate lenses (V2784). You say that you only went for a checkup. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers $200 allowance towards the purchase of frames and lenses. Lens enhancements are 
not covered under this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say that lens enhancements, such as polycarbonate 
lenses (V2784) are not covered under this benefit. Based on this information, we decided that the Plan's rules 
for coverage of polycarbonate lenses (V2784) have not been met. Therefore, we decided that the Plan does not 
have to pay for polycarbonate lenses (V2784) provided on July 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the stationary bicycle purchased on January 1, 
2023. 
 
You asked the Plan to reimburse you for these services. You say that the enrollee cannot go to a gym facility. 
The Plan denied your request. The Plan says the services are not covered. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan reimburses up to 
$150 per calendar year for membership in a qualified health club or fitness facility, covered instructional fitness 
classes, participation in wellness programs, memory fitness activities, acupuncture, and/or covered nutritional 
counseling sessions with a licensed nutritional counselor or registered dietician. The Plans rules for coverage of gym benefits have not been met because personal exercise equipment is not 
covered by this benefit. Therefore, we decided that the Plan does not have to reimburse you for the stationary 
bicycle purchased on January 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot billed with code L4361 for June 20, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims lines billed with codes without a KX, GA or 
GZ modifier will be rejected as missing information. 
 
We looked at the file and Medicare rules. The file shows that procedure code L4361 was not billed with the 
required KX, GA, or GZ modifier. Therefore, we decided that the Plan does not have to pay for the walking 
boot billed with code L4361 for June 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23600 billed for May 3, 2023. 
 
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 code 23600 is 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 23600 is closed treatment of proximal humeral (surgical 
or anatomical neck) fracture; without manipulation. 
 
We find that CPT code 23600 is not supported in the medical record. Specifically, the records don't include 
documentation of closed reduction with restorative treatment. 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 procedure code 23600 billed for May 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 billed for April 5, 2023. 
 
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 code G0481 is 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 G0481 is definitive drug testing, 8-14 drug classes. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, there is no order specifically 
listing which drug(s) are to be tested. 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 procedure 
code G0481 billed for April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusion for therapy provided on January 10, 
2023. 
 
You asked the Plan to pay for intravenous infusion for therapy. You say that you are requesting reconsideration 
for the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for intravenous infusion for 
therapy provided on January 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power scooter received on June 17, 2023. 
 
You asked the Plan to pay for the power scooter. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 power scooter received on June 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit, the orthotics management 
and training, the wrist x-rays, and the betamethasone acetate injection provided on June 12, 2023, the office 
visit provided on June 26, 2023, and the upper extremity magnetic resonance imaging (MRI) provided on July 
3, 2023.  
 
You asked the Plan to waive the cost sharing for the office visits, the orthotics management and training, the x-
rays, the injection, and the MRI. You say that you do not agree with the cost sharing. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each in-person specialist visit, a $35 copayment for each rehabilitation therapy visit, a $25 
copayment for each basic imaging service including x-rays, a $220 copayment for each advanced imaging 
service including MRI, and a 20% coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay a $70 copayment for the office visits ($35 copayment x 2 visits = $70). These 
items/services fall within the physician/practitioner services, including doctor's office visits benefit category. 
You have been asked to pay a $35 copayment for the orthotics management and training. This item/service 
falls within the outpatient rehabilitation services benefit category. You have been asked to pay a $25 
copayment for the x-rays. You have been asked to pay a $210.85 copayment for the MRI because the allowed 
amount for this service is less than the $220 copayment. These items/services fall within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay a $1.28 
coinsurance for the injection ($6.40 allowed amount x .20 = $1.28). This item/service falls within the Medicare 
Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the office 
visit, the orthotics management and training, the wrist x-rays, and the betamethasone acetate injection provided 
on June 12, 2023, the office visit provided on June 26, 2023, and the upper extremity magnetic resonance 
imaging (MRI) provided on July 3, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from September 9, 2022, to 
September 14, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says that the DRG was downgraded. 
 
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 diagnosis code A41.50. 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 services at issue in this case were supported by the medical records. Our physician 
reviewer found that the documentation clearly shows gram-negative bacteremia. Therefore, diagnosis code 
A41.50 is justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services rendered from September 9, 2022, to September 14, 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: Favorable

 
We decided that the Plan has to pre-approve Inpatient Rehabilitation Facility services. 
 
You asked the Plan to pre-approve Inpatient Rehabilitation. You say that you need the additional extensive 
rehabilitation that an inpatient facility will provide. The Plan denied your request. The Plan says that the 
enrollee's condition does not meet all the requirements for inpatient rehabilitation admission. The Plan says 
services may be provided at a lower level of care. 
 
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. We find that the Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request. We find that the plan has not 
substantiated their denial in this case. Despite a request for more information, the plan has not forwarded 
medical records for our review. Therefore, we decided that the Plan must pre-approve Inpatient Rehabilitation 
Facility services. Therefore, we decided that the Plan has to pre-approve Inpatient Rehabilitation Facility 
services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 22, 2023, billed with 
codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405 x 2, 81406 x 2, 81407, 
81408 x 2, 81479 x 3. 
 
You asked the Plan to pay for the genetic testing billed. You say that please find the attached documents, 
review and reconsider the claim for payment. The Plan denied your request. The Plan says panel testing should 
be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 22, 2023, billed with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 
81405 x 2, 81406 x 2, 81407, 81408 x 2, 81479 x 3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious disease pathogen testing rendered on February 
27, 2023. 
 
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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that infectious disease pathogen testing cannot be 
unbundled and billed as individual components. 
 
We looked at the file and Medicare rules. The file shows that the infectious disease pathogen testing was not 
billed as a single unit of service. 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 infectious 
disease pathogen testing rendered on February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95004 billed for date of service August 10, 
2023.  
 
You asked the Plan to pay for procedure code 95004. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 95004 is 80. The MAI value for this code is 3. You billed 82 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 95004 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 95004 billed for date of service August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru Dx urinary tract infection panel testing provided 
April 25, 2023, billed with codes 7150-90 XU, 87481-90 XU, 87641-90 XU, 87653-90 XU, 87798-90 XU, 
87801-90. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says panel testing should 
be billed using one CPT code on the claim. The unbundling of lab codes for PCR panel testing is not 
appropriate. 
 
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 looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Also, the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture 
and sensitivity. Based on this information, we decided that Medicare rules for coverage of the laboratory 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the Altru Dx urinary 
tract infection panel testing provided April 25, 2023, billed with codes 7150-90 XU, 87481-90 XU, 87641-90 
XU, 87653-90 XU, 87798-90 XU, 87801-90.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code E0466 for date of service April 29, 2023. 
 
You asked the Plan to pay for code E0466. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that R06.02 has an Excludes1 note in relation to J96.21. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for code E0466 have not been met. Therefore, we decided that the Plan does not have to pay for 
code E0466 for date of service April 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 10, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 81456 is bundled into payment for 
code 81455. 
 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 81456 
is a column two code to column one code 81455 with a modifier indicator of 0. The column two 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 81456 billed for date of service March 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
May 11, 2023. 
 
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 not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR panel was not billed as a single 
unit of service. 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 urine polymerase chain reaction 
(PCR) panel rendered on May 11, 2023.