Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional prosthetic accessories (L5925, L5964 - 
Ottobock C-Leg) 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that though the medical records provided are more than sufficient to justify the prosthesis as already 
approved by the plan, the certified prosthetist/orthotist (CPO) has misunderstood the allowed coding for the C-
leg in using L5925, and has not satisfied Medicare documentation criteria for L5964.  
 
First, regarding L5925, the Pricing, Data Analysis and Coding (PDAC) contractor has only verified L5828, 
L5845, L5848, and L5856 to bill for the C-leg. L5925 is not among them, and this is because the C-leg does 
not actually feature a manual lock (e.g., a physical switch / button that can be engaged with the hands to lock 
the knee). The electronic locking feature described by the CPO does not qualify as a manual lock. 
 
Secondly, there is no justification or context found in the record to suggest that the enrollee's prosthesis will be 
exposed to unusually harsh environments necessitating additional protection beyond what is provided with a 
typical cover (e.g., L5705, which has already been approved 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional prosthetic accessories (L5925, L5964 - Ottobock C-Leg)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29874 billed for date of service April 17, 
2023.  
 
You asked the Plan to pay for procedure code 29874. You say that this service was necessary and should be 
paid. The Plan denied your request. The Plan says payment for code 29874 is bundled into payment for code 
29881. 
 
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 29874 is a column II code to column I code 29881 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 29874 billed for date of service April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 94010 and 94729 billed for date of service 
January 10, 2023. 
 
You asked the Plan to pay for procedure code(s) 94010 and 94729. You say that you disagree with the denial. 
The Plan denied your request. The Plan says these codes are included in the skilled nursing facility payment 
and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that these services were provided to the enrollee while a SNF inpatient. Per the Physician 
Fee Schedule, CPT codes 94010 and 94729 have a Professional/Technical indicator of 1. This means that CPT 
codes 94010 and 94729 have both a professional and technical component. In this case, CPT codes 94010 and 
94729 have not been billed with an appropriate modifier to indicate the professional component. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 94010 and 94729 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 94010 and 94729 billed for 
date of service January 10, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service July 6, 2023.  
 
You asked the Plan to pay for procedure code 76641. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service July 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided July 16, 2022, to July 29, 
2022. 
 
You asked the Plan to pay for the inpatient stay. You say that please review for payment. The Plan denied your 
request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient stay have been met. 
Additional records were requested from the provider to determine how the enrollee came to the servicing 
provider, whether the billed services were actually performed, or that the services were medically necessary. 
The records show that the Plan made multiple attempts to obtain the needed records without success. 
Therefore, we decided that the Plan does not have to pay for the inpatient hospital stay provided July 16, 2022, 
to July 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve procedure. 
 
You asked the Plan to pre-approve a genicular nerve procedure. You say that you would have relief with this 
procedure. The Plan denied your request. The Plan says this is considered experimental/investigational. 
 
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 pre-approve a genicular nerve procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental therapy, and is the subject of ongoing 
clinical trials. 
 
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 genicular nerve procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve procedure.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided from March 17, 2023, through 
April 29, 2023. 
 
You asked the Plan to pay for the inpatient care. You say that the enrollee did not elect hospice until the date of 
discharge. As such, the claim is payable by the Plan.  The Plan denied your request. The Plan says that this 
claim should be paid by Original Medicare because the enrollee elected hospice.  
 
The Plan must follow Medicare rules. Medicare rules say that the payer responsible on the date of admission 
for an inpatient stay is responsible for paying for the inpatient services.  
 
We looked at the file and Medicare rules. Review of the file shows that the hospice election was made on April 
29, 2023. The enrollee was admitted to this inpatient stay on March 17, 2023. As the Plan was still responsible 
on the date of admission, this claim must be paid by the Plan, not Original Medicare. Based on this 
information, we decided that Medicare rules for coverage of the inpatient care have been met. Therefore, we 
decided that the Plan has to pay for the inpatient hospital care provided from March 17, 2023, through April 29, 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 billed for date of service April 3, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the coding is approved by Medicare. 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 G0481 is definitive drug testing of 8-14 drug classes. We 
find that CPT code G0481 is not supported in the medical record. The records provided show that more than 14 
drug classes were tested. There is a more accurate code that describes the testing provided. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code G0481 billed for date of service April 3, 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 the enrollee needs LTACH care. The 
Plan denied your request. The Plan says the enrollee does not meet requirements for approval of a LTACH 
admission. 
 
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 requested LTACH care is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is receiving appropriate care in the current acute care 
setting as provided by the Plan. The documentation does not support that LTACH services are medically appropriate until the enrollee is stable enough to transfer to a lower level of care. Completion of treatment at 
the current facility is recommended. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service April 28, 
2023, to May 27, 2023. 
 
You asked the Plan to pay for the billed services. You say that the calculation and determinations were based 
on CMS guidelines. The Plan denied your request. The Plan says an incorrect HIPPS code was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim at issue was billed with HIPPS code 1CC31, indicating a 
functional level of high. The OASIS assessment, which shows only partial to moderate assistance, does not 
support this coding. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home health care 
billed for dates of service April 28, 2023, to May 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Transcutaneous Electronic Nerve Stimulator (TENS). 
 
You asked the Plan to pay for a Transcutaneous Electronic Nerve Stimulator (TENS). You say that the item 
was medically necessary. The Plan denied your request. The Plan says the provider is not a Medicare 
contracted provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a Transcutaneous Electronic Nerve 
Stimulator (TENS).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services billed on April 16, 2023, through April 
29, 2023, at the Diagnosis Related Group (DRG) originally billed.  
 
You asked the Plan to pay for the inpatient services at the DRG originally billed. You say that the inpatient 
services should be paid at the DRG originally billed because they were coded accurately. The Plan denied your 
request. The Plan says there is insufficient documentation supporting the codes originally billed, therefore the 
claim is not payable at the DRG originally billed. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. We have confirmed that in this case sufficient medical records for all 
dates of service on the claim have not been received. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of the inpatient services have 
been met.  Therefore, we decided that the Plan does not have to pay for the inpatient services billed on April 
16, 2023, through April 29, 2023, at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210x 17) alveoloplasty in 
conjunction with extraction (D7310 x 4) and inhalation of nitrous oxide (D9230). 
 
You asked the Plan to pre-approve the dental services. You say that you require these procedures. The Plan 
denied your request. The Plan says these services are not covered benefits under your Medicare plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve surgical extractions 
(D7210x 17) alveoloplasty in conjunction with extraction (D7310 x 4) and inhalation of nitrous oxide (D9230).
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 the LTACH admission is the appropriate 
level of care for the enrollee.  The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for LTACH admission. 
 
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 appears to be improving but is still unstable for transfer and requires 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer. The enrollee does not require services at the LTACH that are not already available at the current facility.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223) 
rendered on April 10, 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 this code needs a high level of medical decision making, or 75 minutes of time documented. 
 
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 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded." 
 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 documentation reflects a 
medically appropriate history and exam, but not decision making of high level or that at least 75 minutes were 
spent. 
 
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 evaluation and management services (procedure code 99223) rendered on April 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87798, 87481, 87653, 87640, 87471, 
87641, and 87500) provided on April 12, 2023. 
 
You asked the Plan to pay for the panel testing. 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 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 87798, 87481, 87653, 87640, 87471, 87641, and 87500 are not supported in the 
medical record. Specifically, a panel was performed and there is a more appropriate singular code for the 
services. 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 panel testing (87798, 87481, 87653, 
87640, 87471, 87641, and 87500) provided on April 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office services, imaging, laboratory services, oxygen therapy, 
and medications provided in the Republic of Ecuador from April 12, 2023, to June 2, 2023. 
 
You asked the Plan to pay for outpatient services. You say that you had an emergency during your stay in 
Ecuador. The Plan denied your request. The Plan says these services were not performed in an emergency room 
or urgent care facility so are not covered by the Plan's worldwide benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States are generally not covered. The Plan has a worldwide coverage benefit that goes beyond 
Medicares coverage. The Plan covers worldwide emergency and urgent care. 
 
We looked at the file and Medicare rules. These services were not emergency or urgent care services as they 
were follow-up visits and testing for your condition. Based on this information, we decided that the Plans rules 
for coverage of outpatient services have not been met. Therefore, we decided that the Plan does not have to pay 
for office services, imaging, laboratory services, oxygen therapy, and medications provided in the Republic of 
Ecuador from April 12, 2023, to June 2, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service April 13, 
2023. 
 
You asked the Plan to pay for the billed services. You say that these codes were paid on the facility claim. 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 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 diagnosis code group R60.- has an Excludes1 note in relation to diagnosis 
code group R18.-. This means that diagnosis codes R60.1 and R18.8 cannot be reported together. Based on this 
information, we decided that the Medicare billing rules for the billed services have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99283 billed for date of service April 13, 2023.