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

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service March 8, 
2023, to March 14, 2023.  
 
You asked the Plan to pay for procedure code 88341. You say that you would like the Plan to reconsider their 
denial of payment. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 22 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88341 
billed for date of service March 8, 2023, to March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation services (G0283) provided from 
February 27, 2023, through March 27, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services at issue are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the electrical stimulation services (G0283) provided from February 27, 
2023, through March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months continued use of a home ventilator 
(E0466). 
 
You asked the Plan to pre-approve continued use of a home ventilator. You say that you are requesting 
reconsideration. You need the ventilator because you have COPD. The Plan denied your request. The Plan says 
the request for continued use of non-invasive ventilator (NIV) is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 

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 continued use of a home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you have a diagnosis of 
respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document that the 
home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode which 
is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a 
back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up 
rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a home ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve nine (9) months continued use of a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse to you shoes purchased for your spouse November 28, 
2022, to December 31, 2022, under your wellness wallet benefit. 
 
You asked the Plan to reimburse to you shoes. You say that the initial claim was denied for patient name not 
matching on file. Please honor these receipts. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. Benefits are not transferable to another party. 
 
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 if you receive services not covered by our plan or services obtained out-of-network and were not authorized, you are responsible for 
paying the full cost of services. 
 
You have asked for reimbursement of $234 for shoes. Two of the receipts provided shows the purchases as 
womens sneakers. These items were purchased for another person and not for you. As the member you are the 
contract holder and the benefits that you obtain through your wellness wallet benefit are member level meaning 
the benefit is to be used by only you and not transferable to another party. This means that this denial is correct 
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 reimburse to you shoes purchased for 
your spouse November 28, 2022, to December 31, 2022, under your wellness wallet benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 6, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections.  
 
You asked the Plan to pre-approve facet joint injections. You say that the requested facet joint injections are 
medically necessary The Plan denied your request. The Plan says the requested facet joint injection does not 
meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. 
 
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 facet joint injections. Our reviewer says 
that the requested facet joint injections are not considered medically necessary. Our physician reviewer found 
that two sets of diagnostic MBBs must be performed first and with 80% pain relief each. RFA is not medically 
reasonable and necessary 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99051 billed for date of service March 11, 
2023. 
 
You asked the Plan to pay for procedure code 99051. You say that the services should be paid.  The Plan 
denied your request. The Plan says procedure code 99051 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99051 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99051 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99051 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99051 billed for date of service March 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services billed with code 88305 for March 24, 
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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities.  

We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 pathology services billed 
with code 88305 for March 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hereditary breast and ovarian cancer gene analysis 
(81162). 
 
You asked the Plan to pre-approve hereditary breast and ovarian cancer gene analysis. You say that the enrollee 
has a diagnosis of stage 1 breast cancer and has a family history of metastatic prostate cancer.  The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for coverage of this test. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1 and BRCA2 genetic testing for 
susceptibility to breast or ovarian cancer is covered in adults as medically reasonable and necessary when there 
is a personal history of breast cancer and certain criteria are met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hereditary breast and ovarian cancer gene analysis have not been met. Specifically, the enrollee 
was diagnosed with breast cancer at the age of 79. This means that in order to qualify for coverage of this test, 
the enrollee must have at least two close blood relatives with pancreatic cancer or prostate cancer with a 
Gleason score >7, at least two close blood relatives with breast cancer at any age, at least one close blood 
relative with breast cancer before the age of 50, at least one close blood relative with epithelial ovarian cancer, 
fallopian tube, or primary peritoneal cancer, or one close male blood relative with breast cancer. However, the 
medical records provided indicate that the enrollee has only one close blood relative with prostate cancer, and 
there is no indication that there are any other close family members with the necessary cancer types to meet one 
of these criteria. Therefore, we decided that the Plan does not have to pre-approve hereditary breast and ovarian 
cancer gene analysis (81162).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service March 3, 
2023. 
 
You asked the Plan to pay for procedure code 87640. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
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 87640 
is a column II code to column I code 87641. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 87640 billed for date of service March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair. You say that you need this device 
because you are nearly immobile, and have trouble with your right leg. You also say that you have fallen down 
a few times and with a power wheelchair you could avoid falling and going to the hospital due to the falls. The 
Plan denied your request. The Plan says Medicare's medical necessity criteria have not been met. 
 
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 group 2 standard power wheelchair. 
Our reviewer says that the group 2 power wheelchair (K0823) is not medically necessary. Our physician 
reviewer found you have been experiencing progressive weakness, but are noted to be able to ambulate with 
the assistance of a walker. There is no formal mobility evaluation indicating your overall level of mobility, 
graded motor strength and ability to perform daily activities. Our reviewer found that the documentation does 
not indicate why you cannot use a manual wheelchair for assistance with mobility. Our physician reviewer also 
found that there is a lack of documentation indicating if you can safely use the requested group 2 power 
wheelchair and if your home is accessible for it. 
 
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 group 2 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for codes Q0092 and R0070. We decided that the Plan does not have to 
waive the cost shares for the inpatient services.  
 
You asked the Plan to pay for the physician and radiology services billed for dates of service January 19, 2023, 
to February 10, 2023. You say that you did not have the ability to get authorization. The Plan says that the cost 
shares were applied correctly. 
 
We decided that the Plan has to pay for codes Q0092 and R0070.  
 
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 file shows that the enrollee received portable x-ray services. The services were billed with transportation 
component code R0070 and set-up component code Q0092. There are no procedure-to-procedure edits for 
these codes. These codes are separately payable as billed. Based on this information, the Medicare rules for 
coverage have been met. Therefore, we decided that the Plan has to pay for codes Q0092 and R0070 billed for 
date of service February 10, 2023.  
 
We also decided that the Plan does not have to waive the cost shares for the inpatient services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
The file shows that the enrollee received an out-of-network office visit on January 19, 2023. The enrollee was 
charged a deductible and a $20 copay. The services fall within the physician services benefit category. 
 
The enrollee received physician services during an inpatient stay at an out-of-network facility on January 23, 
2023. The enrollee was charged a 35% coinsurance. The services fall within the inpatient hospital care benefit 
category. The enrollee received 4 days of inpatient hospital care at an in-network facility from January 19, 2023, to 
January 23, 2023. The enrollee was charged a $275 copay for each day. The services fall within the inpatient 
hospital care benefit category.  
 
We looked at the file and the rules. The enrollee has been asked to pay the correct amounts based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from 
January 19, 2023, to January 23, 2023. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided from October 17, 2022, to October 
22, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that You did not provide a specific 
argument with your appeal request. The Plan denied your request. The Plan says that the patient was admitted 
from October 11, 2022, to October 22, 2022. The Plan has paid for the admission for dates October 11, 2022, to 
October 16, 2022. However, the Plan contends that inpatient care was not medically necessary starting on 
October 17, 2022. As of this date, the patient's condition no longer required acute inpatient hospitalization. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for the inpatient hospital services. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient had a change in recommendation by licensed physical and occupational 
therapists for placement rather than home, so the inpatient stay from October 17, 2022, to October 22, 2022, 
was medically necessary for placement as home discharge was deemed unsafe. 
 
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 inpatient hospital services have been met. Therefore, we decided that the 
Plan has to pay for inpatient hospital services provided from October 17, 2022, to October 22, 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: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on August 12, 2022, to August 14, 
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 
billed diagnoses of A40.0 (Sepsis due to streptococcus, Group A) and A40.1 (Sepsis due to streptococcus, 
Group B) are not supported by the medical record. As a result, a lower DRG was paid. The Plan denied your 
request. The Plan says that the diagnoses billed are supported by the medical record, and the DRG should be 
paid as billed 
 
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 diagnoses of A40.0 (Sepsis due to streptococcus, 
Group A) and A40.1 (Sepsis due to streptococcus, Group B). 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 the billed 
diagnoses of A40.0 (Sepsis due to streptococcus, Group A) and A40.1 (Sepsis due to streptococcus, Group B) 
are supported by the medical record. Our physician reviewer found the medical records confirm that the patient 
was admitted with necrotizing fasciitis and kidney injury, with wound cultures growing Group A and Group B 
streptococcus. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on August 12, 2022, to August 14, 2022, at the Diagnosis Related Group (DRG) 
originally billed.  
 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.