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

 
We decided that the Plan does not have to pre-approve peripheral nerve stimulation. 
 
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 a covered benefit for the enrollee's condition. 
 
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 this is considered experimental therapy and it is the subject of ongoing clinical trials. Therefore, the 
request is deemed not medically reasonable and 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve peripheral nerve stimulation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to receive the necessary care. The Plan denied your request. The Plan says the enrollee does not meet the 
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 enrollee is medically stable and the complexity of their medical, rehabilitation, 
and nursing needs does not require an acute hospital inpatient rehabilitation stay with an interdisciplinary 
approach to rehabilitative care. The enrollee does not need physician supervision or intensive therapies in an 
IRF. The enrollees rehabilitation needs can safely be provided in an alternate setting.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A6240 for date of service June 16, 2023. 
 
You asked the Plan to pay for code A6240. You say that you disagree with the Plan's denial. 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 providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates 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 L22 (Diaper dermatitis) has an Excludes1 note in relation to L24.A2 
(Irritant contact dermatitis due to fecal, urinary or dual incontinence). This means that the two diagnosis codes 
cannot be reported together. Based on this information, we decided that the Medicare billing rules for code 
A6240 have not been met. Therefore, we decided that the Plan does not have to pay for code A6240 for date of 
service June 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service May 17, 
2023. 
 You asked the Plan to pay for procedure code 93010. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 
92960. 
 
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 93010 
is a column II code to column I code 92960. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 93010 billed for date of service May 17, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 8, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that an agent of the Plan referred you to this provider as 
being listed with your Plan. The Plan denied your request. The Plan says counselors are not covered by 
Medicare or your Health Plan. 
 
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 psychotherapy provided on 
December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 for date of service  
 
You asked the Plan to pay for procedure code 99215. You say that you disagree with the Plan's denial. 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 providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates 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 I73.9 (Peripheral vascular disease, unspecified) has an Excludes1 note in 
relation to I70.213 (Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral 
legs). This means that the two diagnosis codes cannot be reported together. Based on this information, we 
decided that the Medicare billing rules for procedure code 99215 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99215 for date of service
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that you have a primary diagnosis of arthritis in both 
knees and have been dealing with pain since July. You say that you need this shot to get relief and manage 
pain. The Plan denied your request. The Plan says the request for a Hyalgan injection is denied because the 
records do not show that you have osteoarthritis of the knee. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Hyalgan. Our reviewer says that a 
Hyalgan injection is not medically necessary. Our physician reviewer found that the diagnosis of severe knee 
degenerative joint disease is not supported with x-rays. In addition, it is not documented that you have tried and 
failed all conservative measures, which include multiple non-steroidal anti-inflammatory drugs and a steroid 
injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from January 14, 2023, 
to January 18, 2023.  
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you are 
requesting reconsideration of the overpayment audit findings. The Plan denied your request. The Plan says they 
are upholding the reassignment of the DRG for the inpatient admission. 
 
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. 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 not supported by the medical records. Our physician reviewer found 
that the provided records in this case document that the enrollee presented with a chief complaint of a fall. The 
enrollee was reported to have been down several hours at home. The enrollee had left-sided chest wall pain at 
presentation but no cough or shortness of breath. The imaging showed left fifth through eighth rib fractures and 
lower lobe atelectasis and questionable atypical pneumonia. A test for COVID-19 was positive; no fever, 
hypoxemia or severely elevated white blood cell count was documented. The enrollee was treated with 
analgesics, respiratory treatments, incentive spirometry, remdesivir and dexamethasone. The enrollee was 
discharged to a skilled nursing facility on a Lidocaine patch, Augmentin, oxycodone as well as his usual 
outpatient medications. Overall, the records are more supportive of the fall and rib fractures as the primary 
reason for the hospitalization; DRG 183 rather than DRG 177.   
 
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 rendered from January 14, 2023, to January 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on August 1, 2023, to 
August 5, 2023. 
 
You asked the Plan to pay for the outpatient hospital services provided. You say that the claim is billed 
correctly and should be paid. The Plan denied your request. The Plan says the services provided are not 
separately reportable. 
 
The Plan must follow Medicare rules. Medicare rules say that Outpatient non-diagnostic services that are 
related to an inpatient admission must be bundled with the Part A billing for the inpatient stay. 
 
We looked at the file and Medicare rules. Documentation provided shows that the outpatient hospital services 
were provided within three days of the inpatient admission. Based on this information, we decided that 
Medicare rules for coverage of the outpatient hospital services provided have not been met. Therefore, we 
decided that the Plan does not have to pay for outpatient hospital services provided on August 1, 2023, to 
August 5, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external mobile cardiovascular telemetry with 
electrocardiographic recording (ECG) (93229) provided on June 9, 2023. 
 
You asked the Plan to pay for the ECG. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says that the medical records did not have sufficient documentation to 
support code 93229.  
 
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 93229 is to pay for the external mobile cardiovascular 
telemetry with electrocardiographic recording (ECG). 
 
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 ECG. Our reviewer found that the documentation does 
not contain evidence that the components of this code were performed. Therefore, code 93229 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ECG have not been met. Therefore, we decided that the Plan does not have 
to pay for the external mobile cardiovascular telemetry with electrocardiographic recording (ECG) (93229) 
provided on June 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99309 and G8427 for date of service January 6, 2023. 
 
You asked the Plan to pay for codes 99309 and G8427. 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. 
 
We find that CPT codes 99309 and G8427 are not payable as billed. Specifically, the documentation shows that 
these codes were billed with modifier HE. This modifier is not payable or covered by Medicare. Based on this 
information, we decided that Medicare rules for coverage of codes 99309 and G8427 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 99309 and G8427 for date of service 
January 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77067-26 billed for date of service June 23, 
2023. 
 You asked the Plan to pay for procedure code 77067-26. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 77067-26 is bundled into payment for 
code 77066-26. 
 
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 
77067-26 is a column II code to column I code 77066-26. This claim has not been billed with an appropriate 
modifier to bypass the edit. 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 77067-26 billed for date of service 
June 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from May 22, 2023, to 
May 26, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 032x 
TOB code. 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 home health services rendered from 
May 22, 2023, to May 26, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on June 12, 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 CPT 99283 is more appropriate. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making." 
 
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 an enrollee with a history of 
schizoaffective disorder presented with chest pain after striking his chest with a plastic container. The 
documentation supports an appropriate exam, but not an appropriate history or medical decision making of 
moderate level. 
 
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 emergency room services (procedure code 99284) rendered on June 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 30, 2023, to 
February 3, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that acute 
kidney failure with tubular necrosis is the correct principal diagnosis. The Plan denied your request. The Plan 
says the Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported 
inpatient hospital services with the incorrect DRG. 
 
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, N17.0, defined as acute 
kidney failure with tubular necrosis. 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 not supported by the medical records. Our physician reviewer found that the enrollee did not have a rise 
in creatinine within 48 hours or beyond baseline following appropriate fluid administration to meet criteria for 
acute kidney failure, nor were there any signs from urine testing to show tubular necrosis was present to 
support the code, N17.0 defined as acute kidney failure with tubular necrosis. Therefore, the DRG 309 appears 
more appropriate 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 January 30, 2023, to February 3, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
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 admission is medically necessary for you. The Plan 
denied your request. The Plan says your condition does not meet all of the requirements for inpatient 
rehabilitation admission. The Plan says services may be provided at a lower level of care.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The medical records 
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. It is not a 
reasonable expectation that you 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 reimbursement you for the miscellaneous durable medical equipment 
(DME), reclining power sofa (E1399) miscellaneous durable medical equipment, reclining power loveseat 
(E1399) miscellaneous durable medical equipment, table set (E1399) seat lift mechanism (E0627) unlisted 
special service, delivery and set-up (99199) and sales tax (S9999) purchased April 26, 2023. 
 You asked the Plan to reimbursement you for the DME items. You say that you are appealing the denial for 
reimbursement. The Plan denied your request. The Plan says these items are not covered and was purchased 
from a supplier that does not participate with Medicare. 
 
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 reimbursement you for the miscellaneous 
durable medical equipment (DME), reclining power sofa (E1399) miscellaneous durable medical equipment, 
reclining power loveseat (E1399) miscellaneous durable medical equipment, table set (E1399) seat lift 
mechanism (E0627) unlisted special service, delivery and set-up (99199) and sales tax (S9999) purchased April 
26, 2023.