Persius/hicric huggingface dataset:
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for confusion, a fall and failure to thrive. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The enrollee does 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 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 power scooter (K0800).  
 
You asked the Plan to pre-approve a power scooter. You say that a power scooter is crucial for the enrollee's 
daily living activities and safety. The Plan denied your request. The Plan says the enrollee will use the scooter 
outside the home. There is no documentation that the enrollee cannot use a walker or manual wheelchair to 
resolve mobility limitations.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says that 
this item is not medically necessary. Our physician reviewer found that the enrollee has mobility capability in 
the home. The record does not support she requires a mobility device to access MRADLs in the home.  
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) office visits and treatment with an oncologist to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve office visits. You say that the enrollee had surgery on May 17, 2023, in an 
urgent manner. The follow-up will be just as important. The Plan denied your request. The Plan says the 
requested care can be managed by a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
six (6) office visits and treatment with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee would benefit from this 
medication to help restore function and relieve pain. The Plan denied your request. The Plan says that the 
criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the medication. Our reviewer says that 
the requested use of Euflexxa is not medically necessary. Our physician reviewer found that in this case, the 
enrollee has not completed at least three months of conservative therapy. The documentation does not support 
that the Euflexxa is safe and effective for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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. 
 
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 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. Thoracic restrictive disease is mentioned as a diagnosis justifying the need for a ventilator, but the 
records do not support that diagnosis.  The enrollee's restrictive disease appears to be on the basis of interstitial 
lung disease, not a thoracic etiology. Computed tomography (CT) scans of the chest to do not mention chest 
wall or spinal deformities. There is no diagnosis of neuromuscular disease. There is no arterial blood gas done 
while stable demonstrating chronic carbon dioxide (CO2) retention. 
 
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 ventilator.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve pembrolizumab (J9271) and administration (96413) provided on 
December 6, 2022.  
 
You asked the Plan to pre-approve pembrolizumab and administration. You say that this is supported in the 
records. The Plan denied your request. The Plan says that this is experimental. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve pembrolizumab and administration. Our 
reviewer says that the use of pembrolizumab is Food and Drug Administration (FDA) approved for the 
enrollees diagnosis. Our physician reviewer found the records support that this was safe, effective, and 
medically 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 pembrolizumab and administration have been met. Therefore, we decided that 
the Plan has to pre-approve pembrolizumab (J9271) and administration (96413) provided on December 6, 
2022.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95955, 95861, 95927, and 95908 for date of 
service January 29, 2021. 
 
You asked the Plan to pay for procedure codes 95955, 95861, 95927, and 95908. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services billed are 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. 
 
We find that CPT codes 95955, 95861, 95927, and 95908 are not supported in the medical record. Specifically, 
the technical report did not include documentation of an electroencephalogram (EEG) during nonintracranial 
surgery (carotid surgery); therefore, code 95955 cannot be verified. 
 
The technical report did not include documentation of a needle electromyography for test of 2 extremities with 
or without related paraspinal areas; therefore, code 95861 cannot be verified. 
 
The technical report did not include documentation of a short-latency somatosensory evoked potential study 
about the stimulation of any/all peripheral nerves or skin sites by recording from the central nervous system; in 
the trunk or head; therefore, code 95927 cannot be verified. 
 
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 95908 is a column II code to column I code 
95861 with a modifier indicator of 0. The column II code is therefore not payable. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 95955, 95861, 
95927, and 95908 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 95955, 95861, 95927, and 95908 for date of service January 29, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 87641 and 87500 provided on May 25, 2022. 
 
You asked the Plan to pay for procedure codes 87641 and 87500. 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. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for procedure codes 87641 and 87500 by a contract provider. The file does not show 
that the plan provided notice that procedure codes 87641 and 87500 would not be covered. Under Medicare 
rules, this means procedure codes 87641 and 87500 are considered approved by the plan. Therefore, we 
decided that the Plan has to pay for procedure codes 87641 and 87500 provided on May 25, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95938 for date of service April 4, 2022. 
 
You asked the Plan to pay for procedure code 95938. 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. 
 
In this case, the CPT Code Manual definition of code 95938 is short-latency somatosensory evoked potential 
study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper 
and lower limbs.  

We find that CPT code 95938 is not supported in the medical record. Specifically, train-of-four monitoring is 
bundled with the intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials 
(MEP) and are not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 95938 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95938 for date of service April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a crown upgrade fee provided on January 12, 2023.

You asked the Plan to waive the copayment for the crown upgrade fee. You say that you were given a quote of the services to be rendered. You also say that according to the fee schedule the crown was $425 but the office charged $750, and you believe you may have been charged a lab fee of $325 which you were not made aware of. 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 also clearly says that a contract dentist may charge an additional fee up to $325 for crown material upgrades.

You have been asked to pay a $325 cost-sharing for a crown upgrade fee. The name brand, laboratory processed or in-office processed porcelain/ceramic crown was produced using specialized technique or materials, and is considered a material upgrade. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a crown upgrade fee provided on January 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 13, 2022, to 
June 21, 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 the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis code A41.51, described as 
sepsis due to Escherichia coli [E. coli]. We asked our physician reviewer to carefully review the case file and 
apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed code. Our physician reviewer found that the enrollee is an 86-year-old male who presented to the 
hospital with fever and difficulty walking. He was found to be alert and oriented x 3, had no neurological 
deficits, had creatinine of 1.02, bilirubin 2.1, white blood cell count 19.5, platelets of 171, urine analysis with 
white blood cells, red blood cells, and ketones. He was treated with fluids, antibiotics and acetaminophen for 
suspected urinary tract infection. The enrollee's vitals were stable during the stay. His kidney function appeared 
to be at or near their baseline as it didn't change significantly throughout the hospital stay and remained under 
2.1. There was no noted hypoxia. Although the enrollee's platelets decreased to 141, it was not within 24 hours. 
Therefore, the SOFA score was 1 (bilirubin elevation). Also, there was no evidence of a systemic infection as 
blood cultures were negative. Sepsis 3 criteria was not met. Therefore, the code, A41.51 is not sufficiently 
supported in the documentation for this admission.   
 
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 June 13, 2022, to June 21, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional teeth added to existing partial denture (D5650) 
provided on February 13, 2023. 
 
You asked the Plan to pay for D5650. You say that you were not told that your policy changed. The Plan 
denied your request. The Plan says these services have been correctly denied. 
 
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 four 
additional teeth added to existing partial denture (D5650) provided on February 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84479 billed for date of service December 
16, 2021.  

You asked the Plan to pay for procedure code 84479. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says payment for code 84479 is bundled into payment for code 
84439. 
 
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 84479 
is a column II code to column I code 84439 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 84479 billed for date of service December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87150, 87641 and 87798 
billed for date of service November 30, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, 87150, 87641 and 87798. You say that these 
services are supported in the medical record. The Plan denied your request. The Plan says the payment for 
these services is included in the payment for other services provided on the date in question. 
 
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 codes 87481, 87653, 87150, 87641 and 87798 are column II codes to 
column I codes 87801 and 87500. Codes 87481 and 87653 have not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met for codes 87481 and 
87653. However, codes 87150, 87641 and 87798 were each billed with a modifier.  
 
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 codes 87150, 87641 and 87798. Our reviewer says 
that the XU modifier is not supported for these services. Our reviewer found the XU modifier is used to report 
unusual non-overlapping services. The laboratory report does not include documentation to support that these 
services are distinct because they do not overlap usual components of the main service. Modifier XU cannot be 
verified as laboratory report does not include documentation to support these procedures do not over-lap the 
primary procedures. 
 
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 87481, 87653, 87150, 87641 and 87798 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87653, 87150, 87641 and 
87798 billed for date of service November 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 22 additional physical therapy visits.  You asked the Plan to pre-approve the therapy services. You say that you would like reconsideration based on 
the records submitted.  The Plan denied your request. The Plan says the requested physical therapy visits are 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has achieved normal range of motion for their chronic 
condition. The enrollee is able to continue with a home exercise program and does not require continued input 
from a skilled therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 22 additional physical therapy visits.