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

 
We decided that the Plan does not have to pay for laboratory services (procedure code 83520) rendered on 
August 25, 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. 
 
In this case, the CPT Code Manual definition of code 83520 is ""Immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified." 
 
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 CPT 83520 is not supported. The 
record does not state what the not otherwise specified antigen was that was allegedly tested for. It cannot be 
verified that this service was performed. 
 
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 laboratory services (procedure code 83520) rendered on August 25, 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 admission to the IRF is a medical necessity. The 
Plan denied your request. The Plan says based on the available information, admission to IRF is not reasonable 
and necessary, as your condition does not meet the Medicare rules.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
lumbar spine surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
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 the enrollee is not on the ventilator and does not have complex wound care needs. He 
does not require many hours of skilled nursing care. Therefore, he does not meet an LTACH admission criteria. 
 
 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 LTACH services.
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 a ventilator. You say that the enrollee trialed BiPAP ST and BiPAP AVAPS 
which did not get their ABG lower than the 60s. You say that this was achieved with the trilogy. You also say 
that with time and use with trilogy the enrollee's levels can be maintained and hospital and emergency visits 
will cease to exist. The Plan denied your request. The Plan says ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this respiratory assistive device 
(RAD) policy will be denied as not reasonable and necessary. 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
requested ventilator is not medically necessary. Our physician reviewer found the provided records indicate a 
diagnosis of obesity hypoventilation syndrome (OHS) with thoracic restrictive disease and chronic respiratory 
failure. The reviewer found that there is no documented trial or failure of bilevel positive airway pressure 
(BiPAP) with or without average volume-assured pressure support (AVAPS). The enrollee does not show 
requirements for escalation of therapy. Therefore, the reviewer found that the requested ventilator is 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 a 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is a fall risk, is weak and not able to be 
independent. The Plan denied your request. The Plan says based on the available information, admission to IRF 
is not reasonable and necessary, as the enrollee's condition does not meet the Medicare rules.  
 
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 was admitted to the hospital with COVID-19, vomiting, 2 falls, as well 
as acute kidney injury. The enrollee's current medical issues are stable and while they need services, they do 
not require thrice weekly visits with a rehabilitation physician.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sildenafil tablet. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve sildenafil tablet.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the cataract surgery provided on September 
5, 2023. 
 
You asked the Plan to waive the deductible for the cataract surgery. You say that you paid your $250 
copayment per eye, you should not have to pay a 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 $750 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to 
the cataract surgery. This cost sharing is a contractual obligation that had not been met at the time the cataract surgery that was received on September 5, 2023. Therefore, we decided that the Plan does not have to waive 
the deductible for the cataract surgery provided on September 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment billed for date of service 
August 29, 2023. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the durable medical equipment billed for date of service August 29, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital services provided from July 18, 2023, to July 20, 
2023. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that HCPCS code C1761 should always be billed 
with one of the following CPT codes: 92928, 92933, 92943, C9600, C9602, and C9607. In the code pair sheet, 
Column B shows the pass-through device code C1761. Column C clearly identifies 92928, 92933, 92943, C9600, 
C9602, and C9607 as the appropriate corresponding codes for pass-through code C1761. As code C9600 was on 
that list, it was an appropriate code to bill as shown on the claim at issue. Therefore, we decided that the Plan has 
to pay for the outpatient hospital services provided from July 18, 2023, to July 20, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
October 14, 2022, to October 19, 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 these
services were medically necessary. The Plan denied your request. The Plan says that the billed DRG is not
supported.

Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital
services at the DRG originally billed. In this case, you billed the inpatient services provided with diagnosis
code, A41.59 defined as Other gram-negative sepsis. Our Medical Director states that the enrollee had a
medical history that included advanced dementia, hypertension, Benign prostatic hyperplasia (BPH) and
Gastroesophageal reflux disease (GERD). The enrollee presented to the hospital on October 14, 2022, with
leukocytosis and a urinalysis consistent with urinary tract infection. The enrollee was not ill-appearing, and his
vital signs were normal. The white blood count was elevated (14.85). Chemistries were notable for a blood urea
nitrogen (BUN) equals 30, creatinine equals 1.5, and total bilirubin equals 0.4. Lactate was elevated. A blood
culture obtained on October 14, 2022, was positive for Klebsiella pneumonia. The enrollee was diagnosed with
urinary tract infection, bacteremia, and sepsis. Intravenous fluids and cefepime were administered. At the time
of admission, the enrollee's blood pressure was 103/52. The clinical documentation does not sufficiently
support DRG 872. Sepsis-3 criteria were not met in this case. The removal of diagnosis code A41.59 is
appropriate. Our Medical Director found that the enrollee's condition did not meet Medicare criteria for the
inpatient hospital services provided from October 14, 2022, to October 19, 2022, at the DRG originally billed.

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 to the enrollee from October 14, 2022, to October 19, 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 the laboratory services (87502 and 87634) provided February 
15, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says CPT code 87634-QW and 87502-QW (1 unit) remain not supported. The Plan 
states there is a more appropriate lab panel CP) code, 87999, that should be billed when one or more CPT 
codes are included in the same panel.  
 
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 87502 is infectious agent detection by nucleic acid (DNA 
or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, first 2 types or sub-types. The definition of code 87634 is 
infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe 
technique. 
 
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 laboratory services. Our reviewer found code 87502, the 
documentation submitted was reviewed and does not meet criteria. The laboratory report describes a swab 
tested for influenza virus A and B, and RSV testing by amplified probe technique. In this case, the service 
should be billed as a panel, which a more specific code should be reported. For code CPT 87634, the 
documentation submitted was reviewed and does not meet criteria. The laboratory report describes a swab 
tested for influenza virus A and B, and RSV testing by amplified probe technique. In this case, the service 
should be billed as a panel, which a more specific code should be reported. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87502 and 87634) provided February 15, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, retroperitoneal (eg, renal, aorta, nodes) 
(76775) provided on February 24, 2023. 
 
You asked the Plan to pay for the ultrasound. You say that the service was billed correctly and should be paid. 
The Plan denied your request. The Plan says code 76775 is included in Current Procedural Terminology (CPT) 
93978; therefore, it cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 ultrasound. Our reviewer says that the 
procedure report does not include documentation to support rationale for separate payment of retroperitoneal 
ultrasound and complete duplex scan, and code 76775 cannot be verified. 
 
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 ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for the ultrasound, retroperitoneal (eg, renal, aorta, nodes) (76775) provided on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 for date of service February 5, 2023, 
and procedure code 95816 for date of service February 6, 2023. 
 
You asked the Plan to pay for procedure codes 99214 and 95816. 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 codes 99214 and 95816 are not payable as billed. Specifically, the documentation shows that 
the enrollee was inpatient for date of service February 5, 2023, and February 6, 2023. This means the place of 
service billed on the claim (place of service 22, On Campus-Outpatient Hospital) is incorrect and therefore, 
these codes are not payable as billed. Based on this information, we decided that Medicare rules for coverage 
of procedure codes 99214 and 95816 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99214 for date of service February 5, 2023, and procedure code 95816 for date of 
service February 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) injection. 
 
You asked the Plan to pre-approve the SIJ injection. You say that you are in severe pain and have been getting 
this injection every three months for the past twenty-three years as the result of a severe car accident. The Plan 
denied your request. The Plan says you do not meet the medical necessity criteria. 
 
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections are covered when the 
criteria listed in the Medicare rules section are met. 
 
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 SIJ injection. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found there is no documentation of sacroiliac 
joint imaging, three diagnostic sacroiliac joint maneuvers and no documentation of the degree and duration of 
pain relief from each injection. For these reasons, at this time, the request is deemed not medically reasonable 
and 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 SIJ injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac joint (SIJ) injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wound vac rental (E2402) provided on 
April 17, 2023. 
 
You asked the Plan to waive the coinsurance for the wound vac rental (E2402). You say that the cost share is 
wrong. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for the wound vac rental (E2402). This item/service falls within 
the durable medical equipment (DME) and related supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the wound vac rental (E2402) provided on April 17, 2023.