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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 12, 2022, 
to September 14, 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 J96.01, described as 
Acute respiratory failure with hypoxia. We asked our physician reviewer to carefully review the case file and 
apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed code. Our physician reviewer found that the enrollee is a 68-year-old male who was treated in the 
hospital for pneumonia in the setting of chronic obstructive pulmonary disease. He was placed on low dose 
oxygen support (3L/m), antibiotics, and bronchodilators for shortness of breath. Throughout the hospitalization, 
the enrollee didn't require high flow oxygen support, bilevel positive airway pressure, or vent support and was 
able to successfully be weaned to room air. Therefore, the provided documentation does not sufficiently 
support the code, J96.01, acute respiratory failure.   
 
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 12, 2022, to September 14, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on February 15, 
2023. 
 
You asked the Plan to pay for definitive drug testing. You say that these services were medically necessary and 
are covered by Medicare. The Plan denied your request. The Plan says this testing was not medically necessary 
according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is indicated when certain 
conditions are met.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of definitive drug testing have not been met. Specifically, there is no evidence that a screening test 
with presumptively positive or inconsistently negative results was performed for this enrollee prior to the 
definitive drug testing. There is also no evidence that there was no presumptive drug test available. This means 
that the conditions set in the Local Coverage Determination have not been met. Therefore, we decided that the 
Plan does not have to pay for definitive drug testing (G0483) provided on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service October 11, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the services are 
not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code J3490 was billed to identify Bupivacaine, a local anesthetic. This service is not 
separately billable. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 
billed for date of service October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0277 billed for March 23, 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 G0277 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 G0277 is hyperbaric oxygen under pressure, full body 
chamber, per 30 minute interval. 
 
We find that CPT code G0277 is not supported in the medical record. Specifically, the records do not support 
the four units billed. 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 G0277 billed 
for March 23, 2023.
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 that due to surgery complications and 
hospitalizations the enrollee has lost a lot of strength and requires therapy services. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
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 does not require treatment by multiple therapies. 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 laboratory services rendered on January 2, 2023, to 
January 30, 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 laboratories shall bill the HCPCS panel test code and 
not unbundle the individual components if all components of the HCPCS panel are performed.  
 
We looked at the file and Medicare rules. The file shows that the services were billed as unbundled codes and 
not as one test code. 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 laboratory services 
rendered on January 2, 2023, to January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe 
gingival inflammation  full mouth, after oral evaluation (D4346) and panoramic radiographic image (D3330) 
provided on May 15, 2023. 
 
You asked the Plan to pay for the scaling in presence of generalized moderate or severe gingival inflammation 
and panoramic radiographic image. You say that the provider is under new management and does not 
communicate costs before they do the work. The Plan denied your request. The Plan says your benefit for the 
panoramic radiographic image has already been exhausted. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the scaling in presence of generalized 
moderate or severe gingival inflammation  full mouth, after oral evaluation is not among those covered under 
this benefit. Therefore, we decided that the Plan does not have to pay for scaling in presence of generalized 
moderate or severe gingival inflammation  full mouth, after oral evaluation (D4346). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image  was exhausted on date of service December 27, 
2022. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D3330) 
provided on May 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the criteria for reasonable and necessary are not met as this device has not 
been shown to be safe and effective for treatment of the enrollee's condition. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that 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 the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing, 22 or more drug classes (G0483) 
provided February 6, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you request reconsideration and payment in 
full for the toxicology drug screen performed.  The Plan denied your request. The Plan says under Medicare 
rules, the number of definitive urine drug classes requested are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee complained of chronic neck and back pain and was taking prescribed 
gabapentin and oxycodone only. However, the provided documentation did not clearly show the enrollee had 
any unexpected results from a simple urine drug screening test. Nor was there report of suspicious behavior or 
physical findings suggesting possible illicit drug use or other drug abuse to justify a broad list of confirmation 
testing which is excessive and inappropriate for this clinical situation. Therefore, without sufficient support 
provided this request for definitive drug testing of 22+ drug classes will be considered not medically necessary 
at this time.  
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive drug testing, 22 or more drug classes (G0483) provided February 6, 2023.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says admission to an LTACH does not meet criteria. 
 
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 enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pacemaker and electrode insertion (33208, 33225). 
 
You asked the Plan to pre-approve pacemaker and electrode insertion. You say that this is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan follows Medicare rules. 
 
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 pacemaker and electrode insertion. Our 
reviewer says that there is insufficient documentation to support the medical necessity for implantation of a bi-
ventricular pacemaker. Our physician reviewer found there is no documentation of symptomatic bradycardia. 
While the enrollee has a history of congestive heart failure and left bundle branch block, the left ventricular 
ejection fraction on recent cardiac imaging was 45-50%. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pacemaker and electrode insertion have not been met. Therefore, we decided 
that the Plan does not have to pre-approve pacemaker and electrode insertion (33208, 33225).
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 services are needed for the enrollee's complex 
medical needs to help them return to prior level of functioning. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for admission to an IRF. 
 
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 does not require treatment by multiple therapies. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93970 for date of service April 13, 2023. 
 
You asked the Plan to pay for procedure code 93970. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the diagnosis billed with this claim does not describe the correct issue. 
 
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 93970 is duplex scan of extremity veins including 
responses to compression and other maneuvers; complete bilateral study. 
 
We find that CPT code 93970 is not payable as billed. Specifically, this procedure code was billed with 
diagnosis M79.606 (pain in leg, unspecified). The medical records show that the enrollee had pain in the right 
foot. This means there is a more appropriate/specific diagnosis code that should be billed for the services 
rendered. Based on this information, we decided that Medicare rules for coverage of procedure code 93970 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 93970 for date 
of service April 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 6, 2023, to 
March 23, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that payment should be allowed for 
these services. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 6, 2023, to March 
23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion or replacement of peripheral or gastric 
neurostimulator pulse generator or receiver, direct or inductive coupling (64590). 
 
You asked the Plan to pre-approve a gastric neurostimulator receiver. You say that the requested device was 
cleared for use by the Food and Drug Administration (FDA) in 2022, for the treatment of urgency urinary 
incontinence secondary to overactive bladder syndrome. The Plan denied your request. The Plan says the 
requested procedure is considered experimental or investigational treatment and therefore not covered by the 
plan. 
 
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 gastric neurostimulator receiver. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the FDA granted premarket approval (PMA) for the eCoin leadless tibial 
neurostimulator on March 2, 2022. The device is intended to be used to treat urgency urinary incontinence in 
enrollees intolerant to or having an inadequate response to other more conservative treatments or who have 
undergone a successful trial of percutaneous tibial nerve stimulation (PTNS). In this case, the records show that 
PTNS was not effective. 
 
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 gastric neurostimulator receiver have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an insertion or replacement of peripheral or gastric neurostimulator pulse 
generator or receiver, direct or inductive coupling (64590).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 21, 2023, to 
February 2, 2023. 
 You asked the Plan to pay for the home health services. You say that you are a Medicare-certified provider, so 
no prior authorization is required. The Plan denied your request. The Plan says the NOA was not received. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 22, 2022. The NOA was not received by the Plan, so no payment 
can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health services 
provided from January 21, 2023, to February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9279 billed for date of service September 
9, 2022. 
 
You asked the Plan to pay for procedure code A9279. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code A9279 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A9279 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code A9279 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A9279 billed for date of service September 9, 2022.