Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 7, 2023, to 
March 9, 2023, 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 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says the medical 
records did not have sufficient documentation to clinically validate the diagnosis of E43 (unspecified severe 
protein-calorie malnutrition). 
 
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 E43 defined as unspecified severe protein-calorie 
malnutrition. 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 there was insufficient documentation to support severe 
malnutrition. Therefore, diagnosis code E43 (Unspecified severe protein-calorie malnutrition) is not supported.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 7, 2023, to March 9, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 13101 and 13102 rendered on January 13, 
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 Current Procedural Terminology (CPT) 13101 and 13102 remain 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. 
 
The CPT code manual definition of the denied codes is: 
 
CPT 13101: 
 
Repair, complex, trunk; 2.6 cm to 7.5 cm  
CPT 13102: 
 
Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure) 
 
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 the procedure report describes 
layered closure. This would support intermediate repair. A complex wound repair code would be used for 
repairs that, in addition to the requirements for intermediate repair, require at least one of the following: 
exposure of bone, cartilage, tendon, or named neurovascular structure; debridement of wound edges. The codes 
are not 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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 13101 and 13102 rendered on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the puncture aspiration of abscess, hematoma, bulla, or cyst 
described by code 10160-78 performed on March 10, 2023. 
 
You asked the Plan to pay for 10160-78. You say that 10160-78 should be paid as billed because it was coded 
correctly and modifier -78 was appended. The Plan denied your request. The Plan says 10160-78 is denied 
because documentation does not support this service required a return to the operating room. 
 The Plan must follow Medicare rules. Medicare rules say that when treatment for complications requires a 
return to the operating room, physicians should use modifier -78 in addition to the CPT code that describes the 
services performed. 
 
We looked at the file and Medicare rules. In this case, we confirmed that code 10160 was billed with modifier -
78. Per Medicare rules, modifier -78 is for use when complications from an initial procedure require a return to 
the operating room during the postoperative period. The claim in this case was billed with place of service 11, 
indicating an office setting. There is no indication in the case file that code 10160 was performed in the 
operating room. Based on this information, we decided that Medicare rules for coverage of 10160-78 have not 
been met. Therefore, we decided that the Plan does not have to pay for the puncture aspiration of abscess, 
hematoma, bulla, or cyst described by code 10160-78 performed on March 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
April 01, 2023, to April 02, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not feel the 
copay should apply to the second inpatient admission. 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 $375 
copayment for inpatient hospital care.  
You have been asked to pay a $375 copayment for the inpatient hospital stay. 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. You have been asked to pay a total of $375 for the inpatient hospital stay ($350 copayment 
x 1 day = $375). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on April 01, 2023, to April 
02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (A9270). 
 
You asked the Plan to pre-approve a ramp. You say that the electric chair weighs a lot, and you cannot raise 
and lower the bus chair. You need to be able to transport yourself. The Plan denied your request. The Plan says 
a wheelchair ramp does not serve a primarily medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp (A9270).
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 in need of aggressive inpatient 
rehabilitation. The Plan denied your request. The Plan says that the services the enrollee needs can be provided 
safely in other settings.  
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee was given a trial 
pump from your company and has shown great improvement. The Plan denied your request. The Plan says the 
enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial 
of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Also, 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. Therefore, we decided 
that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic 
appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM device and related supplies.  
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested item is a necessity 
for your care. The Plan denied your request. The Plan says rules for coverage of CGMs and related supplies 
have not been met. 
 
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 you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of a CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a CGM device and related supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anterior lumbar interbody fusion followed by a posterior 
spinal fusion with laminectomy decompression and possible intraspinal synovial facet cyst excision. 
 
You asked the Plan to pre-approve anterior lumbar interbody fusion followed by a posterior spinal fusion with 
laminectomy decompression and possible intraspinal synovial facet cyst excision. You say that anterior lumbar 
interbody fusion followed by a posterior spinal fusion with laminectomy decompression and possible intraspinal synovial facet cyst excision is medically necessary. The Plan denied your request. The Plan says the 
requested anterior lumbar interbody fusion followed by a posterior spinal fusion with laminectomy 
decompression and possible intraspinal synovial facet cyst excision does not meet the Medicare coverage 
criteria. 
 
The Plan follows Medicare rules. Medicare rules say that lumbar spinal fusion is covered when the criteria 
listed in the Medicare rules section of this decision 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 anterior lumbar interbody fusion 
followed by a posterior spinal fusion with laminectomy decompression and possible intraspinal synovial facet 
cyst excision. Our reviewer says that the requested anterior lumbar interbody fusion followed by a posterior 
spinal fusion with laminectomy decompression and possible intraspinal synovial facet cyst excision is not 
considered medically reasonable and necessary in this case. Our physician reviewer found there is no 
documentation of a recent six (6) week trial of physical therapy for back pain. There are no red flag issues for 
surgery 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 anterior lumbar interbody fusion followed by a posterior spinal fusion with 
laminectomy decompression and possible intraspinal synovial facet cyst excision have not been met. Therefore, 
we decided that the Plan does not have to pre-approve anterior lumbar interbody fusion followed by a posterior 
spinal fusion with laminectomy decompression and possible intraspinal synovial facet cyst excision.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92950, 99053, 99291, and 93010 provided 
on February 1, 2022. 
 
You asked the Plan to pay for procedure codes 92950, 99053, 99291, and 93010. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
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 92950 is Cardiopulmonary resuscitation (eg, in cardiac 
arrest). 
 
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 procedure code 92950. Our reviewer says that the medical 
records do not support the billing of procedure code 92950.  Our reviewer found the medical record does not 
include documentation of cardiopulmonary resuscitation (CPR). CPR involves the provision of cardiac life 
support, including chest compressions, ventilation, and emergency defibrillation of the patient. CPT code 
92950 is intended to describe CPR to restore and maintain the patient's respiration and circulation after 
cessation of heartbeat and breathing. This procedure was not found in the documentation. 
 
We also find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99053 is not separately payable. 
 
Lastly, we have confirmed that codes 99291 and 93010 are column II codes to column I code 92950. This 
claim has not been billed with an appropriate modifier to bypass the edit. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 92950, 99053, 99291, and 93010 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 92950, 99053, 99291, and 93010 
provided on February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
August 8, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. 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 pay for the urine polymerase chain reaction (PCR) 
panel rendered on August 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical repair initial inguinal hernia provided on May 31, 
2023. 
 
You asked the Plan to pay for surgical repair initial inguinal hernia. 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 surgical repair initial 
inguinal hernia provided on May 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT scan) of the abdomen and 
pelvis (74177) provided on July 1, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the service was billed correctly and should be paid. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 4, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the CT scan have not been met. Therefore, 
we decided that the Plan does not have to pay for the computed tomography (CT scan) of the abdomen and 
pelvis (74177) provided on July 1, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 23, 2022, to 
September 15, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. 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 23, 2022. The NOA was not received by the Plan until December 
10, 2022. 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 
rendered from August 23, 2022, to September 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on June 05, 2023. 
 
You asked the Plan to pay for surgery. 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 surgery provided on 
June 05, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on September 8, 2023, and billed with codes 87481, 87511, and 87798. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the unbundling of lab codes for PCR panel testing is not 
appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on September 
8, 2023, and billed with codes 87481, 87511, and 87798.