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

 
We decided that the Plan does not have to pay for code 93010, defined as electrocardiogram, routine, with at 
least 12 leads; interpretation and report only, billed for date of service May 13, 2023. 
 
You asked the Plan to pay for 93010. You say that 93010 should be paid as billed because it is supported in the 
record and the diagnosis codes used are valid. 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 R94.31 has an Excludes1 note in relation to I45.81. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for 93010 have not been met. Therefore, we decided that the Plan does not have to pay for code 
93010, defined as electrocardiogram, routine, with at least 12 leads; interpretation and report only, billed for 
date of service May 13, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital admission provided from June 12, 2023, to June 
17, 2023. 
 
You asked the Plan to pay for the inpatient hospital admission. You say that the patient did require aggressive 
care that could not be provided at a lower level as suggested. You also say that the provided documentation 
supports the approval of medically necessary care that the patient received. The Plan denied your request. The 
Plan says that this inpatient admission cannot be approved because the records do not show that the patient did 
not get better within 48 hours and still had certain symptoms/issues. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 admission. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record showed that at the time of inpatient admission it was reasonable for the 
admitting physician to expect that the patient's necessary hospital care (including earlier emergency department 
and/or observation care) would span two midnights with supporting documentation of the patients history and 
comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
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 inpatient hospital admission have been met. Therefore, we decided that the 
Plan has to pay for the inpatient hospital admission provided from June 12, 2023, to June 17, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the TissueCypher Barrett's Esophagus assay (0108U) provided on 
March 22, 2023. 
 
You asked the Plan to pay for the TissueCypher Barrett's Esophagus assay (0108U). You say that the provided 
TissueCypher Barrett's Esophagus assay (0108U) was medically necessary. The Plan denied your request. The 
Plan says that the provided TissueCypher Barrett's Esophagus assay (0108U) was 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 TissueCypher Barrett's Esophagus assay 
(0108U). Our reviewer says that the provided TissueCypher Barrett's Esophagus assay (0108U) was medically 
necessary. Our physician reviewer found because the enrollee had an indication for Barretts esophagus, the 
TissueCypher Test was reasonable and necessary to evaluate for the risk of esophageal cancer. 
 
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 TissueCypher Barrett's Esophagus assay (0108U) have been met. Therefore, 
we decided that the Plan has to pay for the TissueCypher Barrett's Esophagus assay (0108U) provided on 
March 22, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and water 
circulating heat pad with pump (E0217) provided December 22, 2022, to December 31, 2022. 
 You asked the Plan to pay for a pneumatic compression device. You say that these charges are medically 
necessary, and all charge should be paid in full. The Plan denied your request. The Plan says these items are not 
covered by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, these items are not covered benefits of Medicare or the 
Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and water circulating heat pad with pump (E0217) provided 
December 22, 2022, to December 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided March 8, 
2023, to March 28, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the charges are medically 
necessary, and all charges should be paid in full. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided March 8, 2023, to March 28, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee requires treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. There is a reasonable expectation that this 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits 
 
You asked the Plan to pre-approve the therapy services. You say that additional physical therapy visits are 
medically necessary for you. The Plan denied your request. The Plan says you have received 36 physical therapy visits with improvement of function, activities of daily living, ambulation, transfers, mobility, 
and pain and will be given 4 additional physical therapy visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found your records does not indicate the need for continued unique input 
from a skilled therapist based on response to previous therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional physical therapy visits
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on March 10, 2023, billed with 
codes 87502, 87634, 87581, 87486, 87541, 87798 and U0005. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on March 10, 2023, billed with codes 87502, 87634, 87581, 87486, 87541, 87798 and U0005.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show that your rehabilitation needs 
are complex. The Plan says services may be provided at a lower level of care.  
 
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 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.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Viibryd. 
 
You asked the Plan to pre-approve Viibryd. The Plan denied your request. The Plan says that self-administered 
drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Viibryd.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 1, 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 a corrected claim must be submitted. 
 
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 practitioner services provided have 
been met. Specifically, a corrected claim has not been submitted. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on May 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulpal debridement on tooth 14 (D3221) billed for date of 
service April 6, 2023. 
 
You asked the Plan to pay for pulpal debridement on tooth 14 . You say that this was necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
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 pulpal 
debridement when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The billed procedure, D3221, is specifically pulpal debridement on 
primary and permanent teeth for the relief of acute pain prior to conventional root canal therapy. The record shows that on tooth 14 was removed prior to this service, meaning this was not an appropriate procedure or 
billed code. Based on this information, we decided that the Plan's rules for coverage of pulpal debridement 
have not been met. Therefore, we decided that the Plan does not have to pay for pulpal debridement on tooth 14 
(D3221) billed for date of service April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2.  
You asked the Plan to pre-approve a FreeStyle Libre 2. 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of a FreeStyle Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre 2.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 82 units of procedure code 95004 billed for date of 
service June 13, 2023.  
 
You asked the Plan to pay for the billed 82 units of procedure code 95004. You say that this service was 
medically necessary. 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 95004 is 80. The MAI value for this code is 3. You billed 82 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 95004. Our reviewer says that the services at 
issue in this case are not supported by the medical records. Our reviewer found it appears that only 52 units of 
percutaneous allergy skin tests (95004) were provided on June 13, 2023.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95004 have not been met. Therefore, we decided that the Plan does not have to 
pay for the 82 units of procedure code 95004 billed for date of service June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the train of four testing provided on April 4, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the billed code 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 95937o is "Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method". 
 
We find that CPT code 95937o is not supported in the medical record. Specifically, it is inappropriate to bill 
code 95937 for train of four testing. There is no existing code for train of four testing. Train of four testing is 
not separately payable because it is considered bundled into the procedure. Based on this information, we 
decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the train of four testing provided on April 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission provided from May 25, 2023, to May 
26, 2023. 
 You asked the Plan to pay for the inpatient admission. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says there is no documentation from the provider stating that 
the anticipated length of stay was expected to exceed a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record does not show that at the time of the inpatient admission it was reasonable 
for the admitting physician to expect that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights with supporting documentation of the patients 
history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient admission provided from May 25, 2023, to May 26, 2023.