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

 
We decided that the Plan has to pay for inpatient hospital services provided on June 1, 2022, to June 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 the 
medical records support the billing of diagnosis code A41.9 (Sepsis, unspecified organism). The Plan denied 
your request. The Plan says that the medical records do not support the billing of diagnosis code A41.9 (Sepsis, 
unspecified organism). 
 
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. 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 medical records support the billing of diagnosis code A41.9 (Sepsis, unspecified organism). Our 
physician reviewer found the enrollee presented with altered mental status and was found to have a urinary 
tract infection. The enrollee had documented tachycardia, tachypnea, and leukocytosis. The enrollee meets 
criteria for systemic inflammatory response syndrome with a urinary source, and code A41.9 is supported. 
 
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 provided on June 1, 2022, to June 21, 2022, at the Diagnosis Related Group (DRG) originally 
billed.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat bilateral breast reconstruction surgery. 
 
You asked the Plan to pre-approve breast reconstruction surgery. You say that the requested breast surgery is 
considered cosmetic. The Plan denied your request. The Plan says the enrollee has breast asymmetry and is 
wanting that corrected. 
 The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 breast reconstruction surgery. Our 
reviewer says that this surgery is not medically necessary. Our reviewer found the surgery requested is purely 
cosmetic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of breast reconstruction surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat bilateral breast reconstruction surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve the outpatient procedure. You say that the enrollee has tried and failed 
conservative treatments. The Plan denied your request. The Plan says more studies are needed to show that 
genicular artery embolization for treatment of knee osteoarthritis is safe and effective. 
 
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 outpatient procedure. Our reviewer 
says that the requested genicular artery embolization is not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed 
literature that shows this request to be an effective and/or safe treatment for the noted pathology. While the 
studies are noted to be promising, further studies/research is needed to corroborate that geniculate artery embolization is as good as or better than standard treatments for knee osteoarthritis. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested genicular artery embolization is not medically reasonable or 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 the outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular artery embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0241U provided on April 7, 2023. 
 
You asked the Plan to pay for procedure code 0241U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the billing of code 
0241U. 
 
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 0241U is Infectious disease (viral respiratory tract 
infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen 
reported as detected or not detected. 
 
We find that CPT code 0241U is not supported in the medical record. Specifically, the records show that more 
than 4 targets were tested. There is a more appropriate code for the services provided. Based on this 
information, we decided that Medicare rules for coverage of procedure code 0241U have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 0241U provided on April 7, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown-porcelain/ceramic (D2740) for tooth #3. 
 
You asked the Plan to pre-approve the crown. You say that the enrollee has frequent spontaneous pain with hot 
and cold temperatures and biting. You say the enrollee is unable to chew and eat on the right side. The Plan 
denied your request. The Plan says that the criteria for coverage has not been met. 
 
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. The Plan covers the crown 
when the services are medically necessary and reasonable. 
 
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 crown. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the two photos of the tooth show a large 
amalgam filling on it that covers the biting surface of the tooth and also one of the sides of the tooth. There are 
fracture lines noted on the front aspect of the tooth and another fracture on the cheek side of the tooth. The 
amalgam filling is failing and there is decay around the filling. After removal of the filling and the fracture 
lines, the tooth will be structurally compromised and will need a full coverage crown to reduce the risk of 
further fractures developing. The clinical notes support the recommendation for a crown. The enrollee is having 
pain when they bite down, which is an indication of a cracked tooth. When a tooth has cracks, without a full 
coverage crown, the enrollee will have more pain as they bite and the crack gets larger, potentially needing 
more extensive treatment such as a root canal or extraction of the tooth. Based on the records submitted, a 
crown (D2740) is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-
approve a crown-porcelain/ceramic (D2740) for tooth #3.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the inpatient rehabilitation facility services are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not require inpatient 
rehabilitation facility services.  
 
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 the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 15, 2023, billed with 
codes 87635, 87502, 87503, 87486, 87541, 87581, 87651, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that the records demonstration the clinical 
efficacy. 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. The file shows that a respiratory pathogen panel test was provided. We looked at the file and Medicare rules. 
This NGS panel test was not billed with a single 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 15, 2023, billed with codes 87635, 87502, 87503, 
87486, 87541, 87581, 87651, and 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service May 23, 
2023.   
You asked the Plan to pay for procedure code 88341. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the billed number of units are not supported by the 
records as both provided and medically necessary.  
 
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 88341 is 13. The MAI value for this code is 3. You billed 16 units of this 
code, exceeding the MUE.  
 
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 88341. Our reviewer says that the services at 
issue in this case are not supported by the medical records. Our reviewer found that the provided 
documentation supports that additional units were rendered but does not explain why the additional units were 
medically necessary.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 88341 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 88341 billed for date of service May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive hereditary pharmacogenomic testing and the 
hereditary genetic cardiac testing rendered on April 24, 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 denial of this testing was appropriate. 
 
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 pay for the services. 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 whether the requested genetic testing is medically appropriate and necessary. The test is 
described as a genetic based cardiovascular risk factor screening test in which multiple genes are assessed 
using genomic DNA extracted from patient sampling. It assesses the presence of pathogenic or likely 
pathogenic variants in genes known to be associated with increased cardiac risk. It is not a diagnostic test. 
There is no evidence to support its role in this enrollee's clinical management. In summary, the requested 
testing is not considered 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for comprehensive hereditary pharmacogenomic testing and the hereditary genetic cardiac testing 
rendered on April 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87801 billed for date of service March 15, 
2023. 
 
You asked the Plan to pay for procedure code 87801. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says this code is not supported in the records 
provided. 
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
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 procedure code 87801. Our reviewer says that this code is 
not supported in the records provided. Our reviewer found the provider reported a "not otherwise specified" 
procedure code; however, additional documentation of procedure codes reported with the "not otherwise 
specified" code was not included in documentation submitted. In this case, CPT 87801 cannot be verified, as 
the test reported for this procedure code was not documented. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87801 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87801 billed for date of service March 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left atrial appendage closure (LAAC) with Watchman 
procedure. 
 
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 LAAC 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 atrial fibrillation. He 
does not have an elevated congestive heart failure, hypertension, age =75 (doubled), diabetes, stroke (doubled), 
vascular disease, age 65 to 74 and sex category (CHADSVASC) score and there is no documented 
contraindication to anticoagulation. The criteria for coverage are not met and the LAAC procedure 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 left atrial appendage closure (LAAC) with Watchman procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 57283-59 rendered on May 1, 2023. 
 
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 Current Procedural Terminology (CPT) code 57283-59 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found that CPT 
57283-59 is not supported as a separately identifiable procedure. According to CPT rules, there is a more 
specific way to report a colporraphy when performed with a hysterectomy. 
 
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 procedure code 57283-59 rendered on May 1, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on February 13, 2023, billed with 
procedure code 95937-26. 
 
You asked the Plan to pay for the testing services provided. 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 services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95937-26 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
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 testing services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that the procedure report does not include 
documentation of neuromuscular junction testing. 
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on February 13, 2023, billed with procedure code 
95937-26.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the enrollee states their pain is currently a 
7/10 and can get as high as 9/10 without medication. The Plan denied your request. The Plan says this 
procedure is unproven. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.