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

 
We decided that the Plan does not have to pre-approve intravenous moderate (conscious) sedation/analgesia- 
first 15 minutes (D9239), and each subsequent 15 minute increment (D9243 x2). 
 
You asked the Plan to pre-approve the intravenous moderate (conscious) sedation/analgesia- first 15 minutes 
and each subsequent 15 minute increment. You say that you would like this service to be covered. The Plan 
denied your request. The Plan says the documentation did not meet the clinical criteria. 
 
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 
intravenous moderate (conscious) sedation/analgesia- first 15 minutes, and each subsequent 15 minute 
increment 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 intravenous moderate (conscious) 
sedation/analgesia- first 15 minutes, and each subsequent 15 minute increment. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the criteria requires that four or more teeth 
are being extracted, the enrollee's medical history recommends sedation or the patient's anxiety is documented. 
In this case, two teeth are to be extracted (#'s 8 and 10), there was no indication that your medical history 
recommended sedation and there was no narrative indicating the patient's anxiety.  
 
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 intravenous moderate (conscious) sedation/analgesia- first 15 minutes and 
each subsequent 15 minute increment have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), and each 
subsequent 15 minute increment (D9243 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine culture testing billed with code 87086 for date of 
service January 20, 2023. 
 
You asked the Plan to pay for code 87086. You say that this test is a Medicare-covered service. The Plan 
denied your request. The Plan says you did not bill this service with a covered diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that urine culture testing is only covered when billed 
with certain diagnosis codes.  In this case, you billed this service with diagnosis codes Z85.46, C64.1, and 
Z87.442.  Unfortunately, none of these diagnoses is listed as a covered diagnosis for the urine testing 
performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 87086 have not been met. Therefore, we decided that the Plan does not have to pay for urine 
culture testing billed with code 87086 for date of service January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99222 billed for date of service February 17, 2023. 
 
You asked the Plan to pay for code 99222. You say that you were the only neurologist consulting with the 
patient on the date of service in question. The Plan denied your request. The Plan says you billed this claim 
with an incorrect Place of Service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill an accurate Place of Service 
(POS) code on their claims. POS code 21 indicates the service was performed in an inpatient hospital setting. 
POS code 22 indicates the service was performed in an outpatient hospital setting. 
 
In this case, you billed code 99222 with POS 21.  However, the records show that the patient was in an 
observation status at the hospital, which is an outpatient status.  As a result, POS 22 should have been billed 
instead. Therefore, we decided that the Plan does not have to pay for code 99222 billed for date of service 
February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 billed for date of 
service December 15, 2022. 
 You asked the Plan to pay for procedure codes 87481, 87653, and 87798. The Plan denied your request. The 
Plan says payment for codes 87481, 87653, and 87798 is 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 
87481, 87653, and 87798 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 87481, 87653, and 87798 
billed for date of service December 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan' 50-mile limit. 
 
You asked the Plan to pre-approve additional mileage. You say that you need transportation to an appointment. 
The Plan denied your request. The Plan says the requested transportation exceeds 50 miles of driving distance. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. We confirmed that the requested trip is 
greater than 50 miles of driving distance. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional miles for routine transportation beyond the Plan' 50-mile limit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99315 for date of service August 14, 2022. 
 
You asked the Plan to pay for procedure code 99315. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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. 
 
We find that CPT code 99315 is not payable as billed. Specifically, this code was billed with primary diagnosis 
code S72.002S (Fracture of unspecified part of neck of left femur, sequela). Diagnosis code S72.002S is a 
sequela code. This is not acceptable as a primary diagnosis. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99315 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99315 for date of service August 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341-26-XU billed for date of service 
February 17, 2023.  
 
You asked the Plan to pay for procedure code 88341-26-XU. You say that the additional units were medically 
necessary. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341-26-XU is 13. The MAI value for this code is 3. You billed 17 units 
of this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units 
were actually provided, were correctly coded, and were medically necessary. You have not provided any 
specific explanation or argument as to why the excess units were performed. Based on this information, we 
decided that Medicare rules for coverage of procedure code 88341-26-XU have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 88341-26-XU billed for date of service February 
17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the hospital bed. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says a total electric hospital bed is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve total electric hospital 
bed (E0265).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for colonoscopy on February 14, 2023.  
 
You asked the Plan to waive the deductible for colonoscopy. You say that this could not be applied to your 
deductible.  The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1000 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
colonoscopy was received on February 14, 2023. Therefore, we decided that the Plan does not have to waive 
the deductible for colonoscopy on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
February 08, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit for the 
evaluation and management provided on February 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that you were previously approved for items 
that do not fully protect at night. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99231) provided on December 23, 
2022. 
  You asked the Plan to pay for subsequent hospital care (99231). You say that this claim denied as a duplicate in 
error and should be reprocessed for reimbursement. The Plan denied your request. The Plan says the incorrect 
POS code was 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. 
 
In this case, the CPT Code Manual definition of code 99231 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem 
focused interval history; A problem focused examination; Medical decision making that is straightforward or of 
low complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99231 is not supported in the medical record. Specifically, the enrollee was in 
outpatient observation on this date of service, but the inpatient POS code was billed. Based on this information, 
we decided that Medicare rules for coverage of subsequent hospital care (99231) have not been met. Therefore, 
we decided that the Plan does not have to pay for subsequent hospital care (99231) provided on December 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on February 07, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on February 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional months for oxygen concentrator (E1390) 
and portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the oxygen equipment. You say that the remaining quantity denied due to 
meeting capped rental status. The rental from you started on April 8, 2023. Please have the authorization 
reconsidered for full approval. The Plan denied your request. The Plan says additional 10 months exceed the 
Medicare benefit allowance of 36 months. There is no documentation of the need for new equipment due to 
loss or damage. 
 
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. There is no documentation of the need for new equipment due to loss 
or damage. The records indicate that a new prescription was requested due to the enrollees oxygen 
concentrator making beeping noises. The Plan approved for 2 months March 2023 to April 2023 to complete 
the months. After 36 months, the vendor is required to provide contents and services for months 37-60. Based 
on this information, we decided that Medicare rules for coverage of the oxygen equipment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 10 additional months for oxygen concentrator 
(E1390) and portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) You asked the Plan to pre-approve a Freestyle Libre CGM. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the enrollee is not on insulin and does not 
have hypoglycemia, therefore, she does not meet approval for the requested CGM. 
 
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 the enrollee does 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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre continuous glucose monitor (CGM)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum erection device. 
 
You asked the Plan to pre-approve the requested services . You say that  the service should be covered. The 
Plan denied your request. The Plan says the request is not a covered benefit. 
 
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. We find that the requested device is not covered by Medicare or 
your plan. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a vacuum erection device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home sleep testing. 
 You asked the Plan to pre-approve home sleep testing. You say that the enrollee needs this to get treatment for 
sleep apnea. The Plan denied your request. The Plan says home sleep studies are for diagnosis alone which has 
already been done. 
 
The Plan follows Medicare rules. Medicare rules state that sleep testing may be used for diagnosis of OSA. 
 
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 home sleep testing. Our reviewer says 
that the enrollee does not meet criteria for home sleep testing. Our physician reviewer found the enrollee was 
diagnosed with moderate obstructive sleep apnea in 2014 and was prescribed continuous positive airway 
pressure (CPAP) at the time, but stopped using CPAP in 2020. Sleep symptoms have returned. It is reasonable 
to reinitiate CPAP using an auto-titrating device as planned according to the clinical note. Since the diagnosis 
of obstructive sleep apnea is already established, there is no need for a home sleep test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home sleep testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home sleep testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on June 8, 2022, to 
June 13, 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 document supportive evidence of the diagnosis code.  The Plan denied your request. The Plan 
says the documentation does not validate the diagnosis 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 with diagnosis code J96.20, defined as acute and chronic 
respiratory failure, unspecified whether with hypoxia or hypercapnia. 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 physician 
reviewer found that the enrollee was admitted to the hospital with fever and shortness of breath. She was 
diagnosed and treated for an acute exacerbation of chronic obstructive pulmonary disease, and pneumonia. The 
enrollee received appropriate therapy in the emergency department and stabilized medically. The enrollee was 
not treated with bilevel positive airway pressure or other forms of mechanical ventilation. There was no 
evidence of persistent hypoxia or significant alterations in carbon dioxide levels. The documentation does not 
indicate the enrollee had significantly low oxygenation compared to baseline, respiratory distress, altered 
mental status or labored breathing. There were no laboratory values that were consistent with this diagnosis. 
The documentation does not indicate that the treatment ordered by the treating medical providers supported a 
diagnosis code of J96.20.   
 
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 the inpatient hospital services provided on June 8, 2022, to June 13, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic inserts to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve these OON items. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested items can be provided by a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
diabetic inserts to be provided by an out-of-network (OON) provider.