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

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service September 
19, 2022.  
 
You asked the Plan to pay for procedure code 99233. You say that the services were separately identifiable. 
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 99233 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide documentation showing that the excess units were actually 
provided, correctly coded, and medically necessary. Based on this information, we decided that Medicare rules 
for coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99233 billed for date of service September 19, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on October 7, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high 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 use of code 99285 is 
not supported by the records provided. Our reviewer found that the provided medical records do not document 2 out of 3 of an extensive number of diagnoses or management options, an extensive amount and complexity of 
data reviewed, and high risk of complication. 
 
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 the services (99285) provided on October 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service March 9, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the drug was a necessary part of the treatment. 
The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
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 Bupivacaine, identified by CPT code J3490, is a local anesthetic which is not separately payable 
in this case. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed for date 
of service March 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 27, 2022, billed 
with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351 and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 27, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351 and 
81272.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you need this vent machine to prevent you 
from having to go back to the hospital due to the increased CO2 in your body along with COPD. The Plan 
denied your request. The Plan says the request is not medically necessary because your records show that the 
ordered settings for the noninvasive ventilator can be delivered by a bi-level PAP machine with AVAPS 
capability.  
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that you have 
chronic hypercapnic respiratory failure from diaphragmatic disorder and obesity hypoventilation syndrome. 
The record indicates that you were successfully treated with BiPAP. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. You could be treated with a BiPAP machine with AVAPS capability and failure of such a device has 
not been documented. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous measurement of five biomarkers (0061U) 
provided on February 15, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that enclosed are the medical records for review. 
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. 
 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 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. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the transcutaneous measurement of five 
biomarkers (0061U) provided on February 15, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on December 
14, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on December 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF services are necessary because you 
are unable to walk without the assistance of a walker, you tire quickly and get out of breath, and you are a fall 
risk. The Plan denied your request. The Plan says you do 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740 x10) and core buildups (D2950 x10). 
 
You asked the Plan to pre-approve the dental services. You say that you want the Plan to approve the services. 
The Plan denied your request. The Plan says your benefit for the requested item or service has been exhausted 
after the approval for three crowns and core buildups. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted with the Plan's approval of 3 crowns and 
core buildups. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740 x10) and core 
buildups (D2950 x10).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown provided on February 22, 2023. 
 
You asked the Plan to pay for a crown . You say that this should be covered. The Plan denied your request. The 
Plan says a crown is only covered in conjunction with a root canal which hasnt been requested here. 
 
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 a crown 
provided on February 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on April 18, 2022, to 
April 22, 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 
diagnosis of A41.9 (sepsis, unspecified organism) is supported in the medical record. The Plan denied your 
request. The Plan says the billed principal diagnosis of A41.9 (sepsis, unspecified organism) is not supported 
by the medical records. Removal of this diagnosis resulted in a lower DRG being 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 the principal diagnosis of A41.9 (sepsis, unspecified 
organism). 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 principal diagnosis of A41.9 (sepsis, unspecified 
organism) is not supported by the medical record. Our physician reviewer found the enrollee was a then 67-
year-old woman with a medical history that included hypertension. She presented to the hospital on April 18, 
2022, after a fall which resulted on her being on the ground for a prolonged period of time. Her vital signs were 
notable for fever and tachycardia. However, the case file does not contain sufficient documentation of organ 
dysfunction resulting from dysregulated host response to infection.  
 
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 April 18, 2022, to April 22, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion (27280). 
 
You asked the Plan to pre-approve SI joint fusion. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 SI joint fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no SI joint instability, fracture, or lesion. SI joint fusion for degenerative back pain is 
experimental. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusion (27280).
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 you believe that the services requested would help 
the enrollee return to their prior level of function. 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87532 and 13 units of code 87798 billed for 
date of service December 23, 2022. 
 
You asked the Plan to pay for procedure codes 87532 and 13 units of code 87798. You say that these services 
were necessary and were reported correctly. The Plan denied your request. The Plan says these services are not 
supported in the medical record. 
 
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 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 87532 and 13 units of code 87798. Our 
reviewer says that these services are not supported as billed. Our reviewer found that the laboratory report 
documents "Herpes virus-6, amplified probe technique; negative". Code 87532 would therefore be included in 
the panel code reported. In addition, the claim provided reports 13 units of code 87798; however, the laboratory 
report does not support 13 units of service. We are unable to verify the additional units billed in this case. 
 
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 87532 and 13 units of code 87798 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87532 and 13 units of code 87798 
billed for date of service December 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that proton beam radiation therapy 
is a medical necessity for the enrollee. The Plan denied your request. The Plan says proton beam radiation 
therapy is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton beam radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that whether proton therapy affords a benefit over other standard approaches for 
prostate cancer is an area of investigation and remains controversial. To date, there are no compelling data to 
suggest that proton therapy is superior to or more beneficial than intensity-modulated radiation therapy (IMRT)/image-guided radiation therapy (IGRT). The generally accepted standard of care for prostate cancer is 
to only offer proton beam radiation therapy on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months of 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 due to medical necessity. 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 the record indicates 
that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability and failure 
of such a device has not been documented. The elements of the coverage criteria are not satisfied. The 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 of continued use of a home ventilator (E0466).