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

 
We decided that the Plan does not have to pay for outpatient hospital services (78803, A9584) provided on 
February 20, 2023. 
 
You asked the Plan to pay for outpatient services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says this claim was submitted with an 
inappropriate primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that providers must report 
services correctly. Providers must report services with the appropriate CPT code. The rules also say that 
outpatient hospital claims are returned to the provider for correction and edit 113 is invoked when the principal 
diagnosis code reported on the claim is considered a supplementary or an additional code and cannot be used as 
a principal diagnosis.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient services have not been met. Specifically, this claim was submitted with a principal 
diagnosis of Z82.0 (family history of epilepsy and other diseases of the nervous system). Family history codes 
are considered a supplementary or an additional code and cannot be used as a principal diagnosis. Therefore, 
we decided that the Plan does not have to pay for outpatient hospital services (78803, A9584) provided on 
February 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87631 billed for date of service December 
22, 2022.  
 
You asked the Plan to pay for procedure code 87631. The Plan denied your request. The Plan says payment for 
code 87631 is bundled into payment for code 87637. 
 
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 87631 is a column II code to column I code 87637 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 87631 billed for date of service December 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81518) provided on March 22, 2023. 
 
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 the documentation does not support the billed service. 
 
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 81518 is not supported in the medical record. Specifically, the records do not document 
what specific genes were tested. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(81518) provided on March 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission so the enrollee will have the best possible chance at recovery and avoid 
readmission to the short term acute care hospital for complications. The Plan denied your request. The Plan 
says the request for admission to an LTACH is being denied as not medically necessary. 
 
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 receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025), bifocal lenses (V2200), and 
polycarbonate lenses (V2784) provided on December 30, 2022. 
 
You asked the Plan to pay for deluxe frames (V2025), bifocal lenses (V2200), and polycarbonate lenses 
(V2784). You say that it was much cheaper to purchase out-of-network. The Plan denied your request. The 
Plan says your benefit Plan does not cover this out of network vision care service/material. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the deluxe frames (V2025), bifocal lenses (V2200), and 
polycarbonate lenses (V2784) are obtained through an in-network optical provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that any benefit received at a non-network optical 
provider are excluded from coverage. The record shows you went to a non-network optical provider. Based on 
this information, we decided that the Plan's rules for coverage of deluxe frames (V2025), bifocal lenses 
(V2200), and polycarbonate lenses (V2784) have not been met. Therefore, we decided that the Plan does not 
have to pay for deluxe frames (V2025), bifocal lenses (V2200), and polycarbonate lenses (V2784) provided on 
December 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 29, 2022, to 
September 27, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 29, 2022. The NOA was not received by the Plan until January 27, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from August 29, 2022, to September 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on November 28, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making". 
 
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 use of code 99285 is not supported by the records provided. Our reviewer found that the provided records do not document 2 out of 
3 of an extensive number of diagnoses or management options, an extensive amount and complexity of data 
reviewed and, high risk of complication.  
 
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 services (99285) provided on November 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on April 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 pay for the 
topical application of fluoride varnish (D1206) provided on April 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Freestyle Libre 2 reader (E2103) and sensor (A4239) 
provided on April 10, 2023. 
 
You asked the Plan to pay for a Freestyle Libre 2 reader and sensor. You say that you are requesting 
reconsideration and have submitted medical records for review. 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 signed delivery sheet, a valid 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 a Freestyle Libre 2 reader (E2103) and sensor (A4239) provided on April 10, 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 the enrollee meets IRF admission criteria, and their 
ongoing rehabilitation needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says based on Medicare guidelines, the IRF services requested do not meet the 
requirements for approval. 
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for frames (V2020) provided on November 15, 2022. 
 
You asked the Plan to pay for frames (V2020). You say that according to your records, you submitted a claim 
for $130 for glasses post cataract surgery. You also say that the Plan sent payment for $127.40, and that is an 
underpayment. The Plan denied your request. The Plan says that payment was made to both you and the 
enrollee for the same date of service. 
 
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. Specifically, the Plan has not provided any evidence of having already 
reimbursed the enrollee for code V2020 provided on November 15, 2022. There is no documentation to support 
that this code was already paid and that the providers charge is a duplicate. Without this necessary 
information, the Plan has not substantiated their denial reason. Therefore, we decided that the Plan has to pay 
for frames (V2020) provided on November 15, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from March 1, 2023, 
to March 8, 2023. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you should not owe a copayment for 
rehabilitation services after having surgery. 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 a $245 
copayment per day for days 1 to 6 and $0 copayment for additional days for each inpatient hospitalization.  
 
 You have been asked to pay a $1,470 copayment for an IRF stay ($245 per day x 6 days = $1,470). This 
item/service falls within the inpatient hospital care 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 
copayment for an IRF stay provided from March 1, 2023, to March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95165 billed for date of service March 30, 
2023. 
 
You asked the Plan to pay for procedure code 95165. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided 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 find that CPT code 95165 is not supported in the medical record. Specifically, medical records pertaining 
to the date of service at issue have not been provided. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Based on this information, we decided that Medicare rules 
for coverage of procedure code 95165 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 95165 billed for date of service March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the portable oxygen 
concentrator is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee 
has been provided with a stationary oxygen concentrator and portable oxygen tanks to meet her needs for 
supplemental oxygen. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a stationary oxygen concentrator. The records show that the provider does 
not specify the type of portable oxygen that must be dispensed. The records received do not indicate that the 
portable oxygen tank the enrollee currently has, is not meeting her needs for portable oxygen. Additional 
medical records were requested and not received. A stationary oxygen concentrator serves the same purpose as 
a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable 
oxygen concentrator (E1392).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative electroencephalogram (EEG) (95955) 
provided on January 19, 2022. 
 
You asked the Plan to pay for the intraoperative EEG. You say that you would like this claim to be reprocessed 
accordingly. The Plan denied your request. The Plan says the clinical value and effectiveness of an 
intraoperative EEG in the setting of lumbar spine surgery have not been demonstrated in the peer-reviewed 
literature. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the intraoperative EEG. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided medical records and review of the current peer-reviewed medical 
literature do not document that EEG monitoring has been shown in controlled studies in a Centers for Medicare 
& Medicaid Services (CMS) approved journal to result in long term health benefits in patients undergoing 
lumbar spine surgery.  
 
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 intraoperative EEG have not been met. Therefore, we decided that the Plan 
does not have to pay for the intraoperative electroencephalogram (EEG) (95955) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing services (D4342) 
provided on April 27, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for periodontal scaling and root planing services (D4342) provided on April 27, 2023, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 18, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that D29.1 has an Excludes1 note in relation to N40.1. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
services provided on April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 87798 for date of service February 16, 2022. 
 
You asked the Plan to pay for code 87798. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services rendered were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for code 87798. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee a history of diabetes had a wound on the right fifth toe. Sample was taken from the wound for the polymerase chain reaction (PCR) panel. The guidelines do not support the clinical utility of 
multiplex PCR panels in the diagnostic work-up of wound infections. Standard of care consists of standard 
culture techniques for the pathogen of concern. Therefore, the enrollee did not meet criteria for the services 
rendered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87798 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 87798 for date of service February 16, 2022.