Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4261) and the bone replacement graft 
(D4263) for tooth #30 provided by an out-of-network provider on January 24, 2023. 
  
You asked the Plan to pay for the dental services. You say that you were told the dental services would be 
covered and the procedures were medically necessary. The Plan denied your request. The Plan says the denial 
of payment for these services is correct, because the osseous surgery and the bone replacement graft are not 
covered by the Plan. Also, it was verified that the proper dental benefits were given prior to the date of service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
osseous surgery (D4261) and the bone replacement graft (D4263) for tooth #30 provided by an out-of-network 
provider on January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transit system (K0108) and electronic connection 
(E2310).  
 
You asked the Plan to pre-approve the wheelchair accessories. You say that please reconsider the 
documentation provided for the K0848 base and all recommended components needed to meet the enrollee's 
current medical, mobility and functional needs. The Plan denied your request. The Plan says these items do not 
meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The transit option does not serve a medical purpose and is not 
covered. The electronic connection is being requested to control approved power seat elevation system E2300, 
which is not covered. Based on this information, we decided that Medicare rules for coverage of the wheelchair 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve transit system 
(K0108) and electronic connection (E2310).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87641, 87481, and 87653 billed for date of 
service October 14, 2022. 
 
You asked the Plan to pay for procedure codes 87641, 87481, and 87653. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 87641, 
87481, and 87653 are bundled into payment for code 87801. 
 
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 codes 
87641, 87481, and 87653 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. 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 codes 87641, 87481, and 87653 
billed for date of service October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213-25) provided on January 20, 2023.  
You asked the Plan to pay for the office visit . You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
This code is included in the global day period of Current Procedural Terminology (CPT) code 20610; this 
means, it cannot be separately reimbursed. The submitted documentation does not support a significant, 
separately identifiable evaluation and management service to support the use of the -25 modifier. 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 office visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
office visit (99213-25) provided on January 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infectious agent drug susceptibility phenotype 
prediction using regularly updated genotypic bioinformatics (87900) provided on February 3, 2023. 
 
You asked the Plan to pre-approve the service. You say that the claim should be paid. The Plan denied your 
request. The Plan says the enrollee does not have a covered diagnosis for this testing. 
 
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the reviewed documentation indicates that the standard urinary tract infection investigation with 
antibiotic testing is available in-network; and there was no documentation submitted to support the medical 
necessity of these services being obtained out-of-network. The review has determined that the items/services at 
issue in this case were 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve infectious agent drug susceptibility phenotype prediction using regularly updated 
genotypic bioinformatics (87900) provided on February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on February 20, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for physical therapy services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided on February 
20, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this equipment is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that this device is not medically necessary. Our physician reviewer found the records do not support the need for a ventilator. The enrollee's needs during sleep can be met with a BiPAP machine. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from August 23, 2022 to 
September 4, 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 from the 
circumstances of this enrollee's admission, physician documentation, clinical picture, and management of the 
current case, it is clear that coding N17.0; Acute kidney failure with tubular necrosis as secondary diagnosis 
was correct. The Plan denied your request. The Plan says DRG 492 is not supported as the diagnosis of Acute 
kidney failure with tubular necrosis. 
 
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, N17.0, defined as Acute 
kidney failure with tubular necrosis. 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 submitted DRG is not 
supported. Our physician reviewer found the enrollee was hospitalized with a known fracture leading to 
immobility, dehydration/prerenal azotemia and possible/mild rhabdomyolysis.  The enrollee responded 
promptly to intravenous fluids and medication holds/avoidances. Our reviewer found that there is no evidence 
of intrinsic/cellular kidney damage. Our physician reviewer found that as such, a diagnosis of acute tubular 
necrosis (ATN), and the billing of N17.0, is not supported.   
 
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 from August 23, 2022 to September 4, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 8, 2022, to 
March 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 
medical records support the diagnoses billed. The Plan denied your request. The Plan says the billed principal 
diagnosis of J15.6 (pneumonia due to other gram-negative bacteria) is not supported in the medical record. 
There was no microbiological confirmation of a gram-negative organism to validate this diagnosis. As a result, 
a lower DRG was paid. 
 
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 principal diagnosis of J15.6 (pneumonia due to 
other gram-negative bacteria). 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 billed principal diagnosis of J15.6 
(pneumonia due to other gram-negative bacteria) is not supported by the medical record. Our physician 
reviewer found the enrollee presented with shortness of breath.  She was treated for pneumonia.  There is no 
evidence that a gram-negative organism was ever identified as the cause of the enrollees pneumonia.  As such, 
the billing of J15.6 is not supported.  
 
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 March 8, 2022, to March 14, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 30, 2023, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an OON office visit. You say that the provider you saw is your primary care 
physician. The Plan denied your request. The Plan says the provider at issue was out-of-network, and the 
service was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that OON services require 
a referral or approval in advance. 
 
We looked at the file and Medicare rules. The service at issue was not authorized. Based on this information, 
we decided that Medicare rules for coverage of an OON office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit provided on January 30, 2023, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contrast injection(s) for radiologic evaluation of existing 
central venous access device, including fluoroscopy, image documentation and report (36598) provided on 
November 28, 2022. 
 
You asked the Plan to pay for the service. You say that you are requesting reconsideration for services advising 
the claim was submitted with the appropriate modifier and should pay. The Plan denied your request. The Plan 
says the code edit invoked appropriately and this will be an uphold.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
A required anatomical modifier appears to be missing. According to the 2022 October CMS Medicare 
Physician Fee Schedule (MPFS), CPT 36598 is listed with a bilateral surgery indicator of "1" which means that 
payment adjustment for bilateral (RT and LT) procedures can apply. 1 = 150 percent payment adjustment for 
bilateral procedures applies. Based on this information, we decided that Medicare rules for coverage of the 
service have not been met. Therefore, we decided that the Plan does not have to pay for the contrast injection(s) 
for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation 
and report (36598) provided on November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (E1230). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you need the power operated vehicle 
to help you so you can do things at home because you live alone. The Plan denied your request. The Plan says 
there is no documentation provided to indicate that you are unable to safely perform your mobile activities of 
daily living without the use of a power operated vehicle. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 power operated vehicle. Our reviewer 
says that a power operated vehicle is not medically reasonable and necessary for you. Our physician reviewer 
found the documentation available for review does not support that you require a power mobility device to 
accomplish mobility related self-care tasks in the home. Our reviewer also found that there is no indication you 
are unable to use an alternative assistive device. 
 
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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated vehicle (E1230).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 22, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to make additional payment for the home health services provided from August 5, 
2021, through September 1, 2021. 
 
You asked the Plan to make additional payment for the home health services. You say that the claim should be 
paid as billed. The Plan denied your request. The Plan says that a review of the original denial was not done as 
the time frame for the appeal decision was missed. 
 
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. The Plan has not provided a rationale to justify the reduction in payment for 
these services. As such, we find that the denial is not substantiated.  Therefore, we decided that the Plan has to 
make additional payment for the home health services provided from August 5, 2021, through September 1, 
2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D4265). 
 
You asked the Plan to pre-approve the dental services. You say that this procedure is necessary to prevent an 
infection. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
plan. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
biologic materials to aid in soft and osseous tissue regeneration (D4265).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is not independent and wants to get 
back to independence. The Plan denied your request. The Plan says that the services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee continues to be non-ambulatory and require maximum assistance with bed 
mobility and transfers. In order to qualify for skilled nursing facility care, the enrollee should demonstrate the 
potential for improvement with therapy services, including physical and occupational therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.