Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99418 billed for date of service March 30, 
2023. 
 
You asked the Plan to pay for procedure code 99418. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 99418 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99418 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99418 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99418 billed for date of service March 30, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services billed with diagnosis code J96.21 rendered 
from July 21, 2022, to July 28, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says that the DRG was updated. 
 
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 DRG 177 with diagnosis code J96.21. 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 services at issue in this case were supported by the medical records. Our physician 
reviewer found that the enrollee has underlying chronic respiratory failure and presented with acute on chronic 
respiratory failure due to pneumonia. Therefore, the documentation does support code J96.21. The 
documentation supports DRG 177 more than DRG 178. 
 
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 billed with diagnosis code J96.21 rendered from July 21, 2022, to July 28, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 6, 2022, to June 
10, 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 
clinical documentation supports the diagnoses billed. The Plan denied your request. The Plan says the 
secondary diagnosis of G93.41 (metabolic encephalopathy) is not supported by the medical record. As a result, 
a lower DRG was paid. 
 
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 secondary diagnosis of G93.41 (metabolic 
encephalopathy). 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 secondary diagnosis of G93.41 
(metabolic encephalopathy) is not supported by the medical record. Our physician reviewer found clinically the 
patient did not appear confused and on exam was reported to be awake, alert, and oriented x 4. The medical 
work up showed a mildly elevated BUN suggestive of mild dehydration. Otherwise, the labs did not show acute 
hematologic, electrolyte or other metabolic abnormalities. Remaining work up also did not raise concern for 
systemic illness.  
 
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 6, 2022, to June 10, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse to you for a touchdown brown power lift recliner 
purchased September 23, 2023 
 
You asked the Plan to reimburse to you for power lift recliner . You say that this item was medically necessary 
due to the enrollee having Parkinson's disease. The Plan denied your request. The Plan says this item is not 
covered 
 
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 reimburse to you for a touchdown brown power lift recliner purchased 
September 23, 2023
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the portable oxygen concentrator (E1392) and 
non-covered item or service (A9270) purchased March 6, 2023. 
 
You asked the Plan to reimburse you for the oxygen equipment. You say that prior to purchasing the system, 
you telephoned the Plan to verify coverage. You were assured that the Plan would cover the cost and that is 
why you purchased the portable oxygen system. 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 the Plan will cover for 
the rental of oxygen equipment.  
You have asked for reimbursement of $3,379 for the purchased oxygen equipment. The Plan does not allow for 
purchase of oxygen equipment This item/service falls within the Durable medical equipment (DME) and 
related supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen concentrator 
(E1392) and non-covered item or service (A9270) purchased March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing (0117U) provided on November 15, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this code is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Local Coverage Article A58801 provided a list 
of codes that are non-covered for pharmacogenomic testing.  
 
We looked at the file and Medicare rules. Per A58801, code 0117U is not covered for pharmacogenomic 
testing. Based on this information, we decided that Medicare rules for coverage of the testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the testing (0117U) provided on November 
15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on February 17, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you did not know that the initial visit was 
non-covered. The Plan denied your request. The Plan says that chiropractic services other than the manual 
subluxation of the spine are not covered. This includes office visits. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided on February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on February 28, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on February 28, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 11, 2022, 
to September 15, 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 you 
disagree with the denial. The Plan denied your request. The Plan says the DRG is not supported. 
 
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 G93.41. 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 records do not support the billing of diagnosis code G93.41. Our physician reviewer found the records 
do not support a change in mental status beyond baseline and supported by neurological examination. There is 
no clinical laboratory evidence of metabolic encephalopathy. The records do not support the billing of G93.41.  
 
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 September 11, 2022, to September 15, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 28, 2022, to 
October 1, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital admission was 
medically necessary.  The Plan denied your request. The Plan says that the inpatient hospital admission was not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record did show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from September 28, 2022, to October 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies (A4450, A6446, A6252) provided 
February 2, 2023, an out of network provider. 
 
You asked the Plan to pay for the wound care supplies. You say that the enrollee has an approved admission in 
a nursing/rehabilitation facility as a resident. As such, the enrollee is entitled to receive surgical dressings as a 
covered benefit. The Plan denied your request. The Plan says enrollees must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered.  
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wound care supplies were used in a SNF or hospital. The requested provider in this case 
is not a network provider with the Plan. The Plan had network providers available who could have provided the 
items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. Therefore, we 
decided that the Plan does not have to pay for the wound care supplies (A4450, A6446, A6252) provided 
February 2, 2023, an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies, skin barrier, wipes or swabs 
(A5120). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have been using 2 wipes per 
catheter for many years, and now they are being denied. Without these wipes, the condom catheters are almost 
useless. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, skin 
barrier, wipes or swabs (A5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 20, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. 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 Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on March 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 57282-XU provided on August 26, 2022. 
 
You asked the Plan to pay for procedure code 57282-XU. You say that the medical records support code 57282 
as distinct from code 58262. The Plan denied your request. The Plan says the medical records do not support 
code 57282 as distinct from code 58262. 
 
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 57282 is a column II code to column I code 58262; however, 57282 
was 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 code 57282-XU. Our reviewer says that the 
medical records do not support code 57282 as distinct from code 58262. Our reviewer found the medical 
records do not indicate that procedure 57282 was done separately from approved procedure code 58262. Per 
CCI edits procedure code 57282 is encompassed within code and surgery 58262. 
 
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 code 57282-XU have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 57282-XU provided on August 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral occlusal device billed with code D7880 for February 
6, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that claims for code D7880 should not be submitted to 
Medicare. 
 
We looked at the file and Medicare rules. The file shows that the oral occlusive device was billed with code 
D7880. 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 oral occlusal device billed with code 
D7880 for February 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87631) provided on July 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis 
code is not covered for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that Local Coverage Article A58575 provides a list of 
covered diagnosis codes for code 87631.  
 
We looked at the file and Medicare rules. The claim in this case was billed with diagnosis codes R05.9 and 
J43.9. Per A58575, these diagnosis codes are not covered for code 87631. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services (87631) provided on July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint denervation (64633, 64634). 
 
You asked the Plan to pre-approve facet joint denervation. 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 follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch (MB)) nerves are considered medically reasonable and necessary for patients who meet certain criteria. 
 
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 denervation. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the previous C2-C3, C3-C4, 
and C4-C5 radiofrequency ablations were in 2020. The review has determined that the enrollee does not meet 
the coverage criteria detailed in the LCD. 
 
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 denervation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint denervation (64633, 64634).
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 due to the enrollee's high prior level of function, they 
would greatly benefit from intensive rehabilitation, a multidisciplinary approach, rehabilitation nursing and 
daily physician oversight. You say the enrollee is not appropriate for a lower level of care due to their medical 
complexity. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. 
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.