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

 
We decided that the Plan does not have to pay for procedure code 73020 billed for date of service October 28, 
2022. 
 You asked the Plan to pay for procedure code 73020. You say that the patient had two x-rays at separate times. 
The Plan denied your request. The Plan says payment for code 73020 is bundled into payment for code 73030. 
 
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 code 73020 
is a column II code to column I code 73030. 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 code 73020 billed for date of service October 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 6, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have supplied medical records to support 
payment. The Plan denied your request. The Plan says you billed these services with an inappropriate pair of 
diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of G54.3 and M51.37. Code M51.37 is an Excludes1 code 
under code G54.3, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on March 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services.  
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 the 
dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiological services (71046-26) provided on March 16, 
2023. 
 
You asked the Plan to pay for the service. You say that the claim was billed correctly. The Plan denied your 
request. The Plan says 71046-26 is not supported when billed with diagnosis code Z11.1. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The provider reported services with diagnosis for screening for 
respiratory tuberculosis. The asymptomatic diagnosis billed does not support the need for a chest x-ray.  
 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the radiological services (71046-26) provided on March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services billed with code 99308 provided on March 10, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for code 99308. You say that this service was medically necessary.  This service was 
provided in good faith and in the best interest of the patient. The Plan denied your request. The Plan says 
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 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 services billed with code 99308 provided on 
March 10, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services billed with DRG 338 
rendered from November 17, 2022, to November 21, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was downcoded from DRG 338 to 
DRG 340. 
 
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 DRG 338 or diagnosis code E43. 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 services at issue in this case were not supported by the medical records. Our 
physician reviewer found that the enrollee presented with ten days of abdominal pain. She was found to have 
perforated appendicitis. Following surgery, the enrollees diet was slowly advanced, and she was subsequently 
discharged. While there is evidence of acute anorexia and mild weight loss related to her illness, there is no 
evidence of chronic weight loss, low body mass index (BMI) or severe malnutrition.  Furthermore, there is no 
evidence that severe malnutrition affected the course of the hospitalization. As such, the billing of E43 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 acute inpatient hospital services billed with DRG 338 rendered from November 17, 2022, to November 21, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve referral to an out-of-network (OON) skilled nursing 
facility (SNF). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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 
referral to an out-of-network (OON) skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zometa. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Zometa is not approved by the Food 
and Drug Administration (FDA) for your diagnosis. Its use is not supported by one of the major drug 
compendia or by clinical research that appears in a Medicare-approved medical journal. Zometa is therefore not reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Zometa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, swallowing function, with 
cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when performed, 
contrast (e.g., barium) study, a radiologic examination, spine, cervical; 2 or 3 views, a radiologic examination, 
chest; single view, a radiologic examination, upper gastrointestinal tract, including scout abdominal 
radiograph(s) and delayed image(s), when performed; single-contrast (e.g., barium) study provided on 
December 20, 2022. 
 
You asked the Plan to pay for a radiologic examination, swallowing function, with 
cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when performed, 
contrast (e.g., barium) study, a radiologic examination, spine, cervical; 2 or 3 views, a radiologic examination, 
chest; single view, a radiologic examination, upper gastrointestinal tract, including scout abdominal 
radiograph(s) and delayed image(s), when performed; single-contrast (e.g., barium) study. You say that the 
services were medically necessary. The Plan denied your request. The Plan says the studies were performed at 
a nursing home (via mobile van/portable x-ray), which are denied as an excluded place of service. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a radiologic examination, swallowing function, with cineradiography/videoradiography, 
including scout neck radiograph(s) and delayed image(s), when performed, contrast (e.g., barium) study, a 
radiologic examination, spine, cervical; 2 or 3 views, a radiologic examination, chest; single view, a radiologic 
examination, upper gastrointestinal tract, including scout abdominal radiograph(s) and delayed image(s), when 
performed; single-contrast (e.g., barium) study have not been met. Therefore, we decided that the Plan does not 
have to pay for a radiologic examination, swallowing function, with cineradiography/videoradiography, 
including scout neck radiograph(s) and delayed image(s), when performed, contrast (e.g., barium) study, a 
radiologic examination, spine, cervical; 2 or 3 views, a radiologic examination, chest; single view, a radiologic 
examination, upper gastrointestinal tract, including scout abdominal radiograph(s) and delayed image(s), when 
performed; single-contrast (e.g., barium) study provided on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous nerve ablation system (64628, 
64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you request prior authorization for 
intraosseous ablation of the basivertebral nerve which is accomplished with the Intracept procedure. The Plan 
denied your request. The Plan says this procedure is considered experimental, investigational and unproven 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 looked at the file and Medicare rules. This procedure is listed in the Plan's Medical Coverage Policy 
Number 0139 Minimally Invasive Spine Surgery Procedures and Trigger Point Injections, as experimental and 
investigational. Based on this information, we decided that Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept 
intraosseous nerve ablation system (64628, 64629).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiological services (71045-26-77) provided on January 
14, 2023. 
 
You asked the Plan to pay for the services. You say that the claim is billed correctly. The Plan denied your 
request. The Plan says procedure code 71045-26-77 is not supported when billed with diagnosis code F17.200. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria. The diagnosis reported, does not support procedure 
performed. Codes 71045, 71046, 71047, and 71048, will be denied if the only diagnosis on the claim is for lung 
cancer screening or nicotine use/dependence. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the radiological services (71045-26-77) provided on January 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital services billed with diagnosis codes 
A41.9 and R65.20 rendered from January 19, 2023, to January 22, 2023. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG and principal diagnosis code is not 
supported. 
 
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 DRG 871. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented with a pleural effusion and pneumonia, in the setting of likely lung cancer. The 
enrollees white count was elevated on admission, which is consistent with both pneumonia/infection and 
cancer/inflammation, and increased during the hospitalization, in keeping with the administration of 
steroids.  The enrollees cachexia and ill-appearance are attributable to his lung cancer. There is no evidence 
that the enrollee had systemic signs of infection, including fever, hypotension, hypoperfusion or organ 
failure. As such, a diagnosis of sepsis, and the billing of A41.9, 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 acute inpatient hospital services billed with diagnosis codes A41.9 and R65.20 rendered from January 19, 
2023, to January 22, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (procedure code 99222) rendered on August 5, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the documents do not support this level of care. 
 
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 99222 is "Initial hospital care, per day, for the evaluation and management of a patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of moderate 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 problem(s) requiring admission are of moderate severity. Typically, 50 
minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that while the history of present illness is 
a bit lacking in detail, the history as a whole is comprehensive, including a history and physical, previous 
medical history, past surgical history, family medical history, social history, medication list, allergy list, and 
comprehensive review of systems. Along with the comprehensive examination and moderately-complex 
medical-decision-making, the billing of CPT 99222 is supported. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
initial hospital care (procedure code 99222) rendered on August 5, 2022.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87500 and 87641 rendered on February 9, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 87500, the 
laboratory report does not include any documentation of this procedure. In terms of CPT 87641, the provider 
also reported CPT 87801. The laboratory does not support CPT 87641 as a separate service.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87500 and 87641 rendered on February 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulatory infusion pump (E0781) provided on February 
16, 2023. 
 
You asked the Plan to pay for an ambulatory infusion pump. You say that the item at issue is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must specify whether equipment is rented 
or purchased. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an ambulatory infusion pump have not been met. Specifically, this durable medical equipment 
claim has been billed with modifier RR, indicating the equipment is to be rented. However, the claim has not 
been reported with a required modifier (KH, KI or KJ) to indicate the duration of rental.  Therefore, we decided 
that the Plan does not have to pay for an ambulatory infusion pump (E0781) provided on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim crowns (D2799). 
 
You asked the Plan to pre-approve interim crowns. You say that this should be covered. The Plan denied your 
request. The Plan says this is not paid separately because this is not an approved service. 
 
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 
interim crowns (D2799).