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

 
We decided that the Plan does not have to pre-approve Rybelsus. 
 
You asked the Plan to pre-approve the medication. You say that you would like to appeal this denial. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rybelsus.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 94618, 94761, and 99072, billed for date of 
service February 1, 2022.  
 
You asked the Plan to pay for procedure codes 94618, 94761, and 99072. The Plan denied your request. The 
Plan says payment for codes 94618, 94761, and 99072, is bundled. 
 
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 94618 
is a column II code to column I code 94621 with a modifier indicator of 0. We have also confirmed that code 
94761 is a column II code to column I code 94618 with a modifier indicator of 0. The column II codes are 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met.  
 
We also find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 94618, 94761, and 99072 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 94618, 94761, and 99072, billed for date of service February 1, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 15,2022, 
through June 21, 2022, and billed with diagnosis code N17.0. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis N17.0 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of N17.0 
 
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 code N17.0- (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 documentation does not support the 
secondary diagnosis of N17.0- (Acute kidney failure with tubular necrosis). Our physician reviewer found the 
member presented with altered mental status. The member was found to have had another stroke. There was 
mild elevations in the member's blood urea nitrogen (BUN) and Chromium Toxicity (CR) was elevated, with 
no evidence of overt renal failure or tubular necrosis.  As such, the billing of N17.0 is not supported.  
 
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 15,2022, through June 21, 2022, and billed with diagnosis code 
N17.0.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on March 01, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you are disputing the share cost. 
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 you must pay a $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 waive the copayment for an office visit provided on March 01, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (87481, 87798) provided on October 27, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the tested were performed as ordered by the 
referring physician. The Plan denied your request. The Plan says that this claim is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case medical records are needed to review the medical necessity of this 
testing. Only the lab report was provided. There is no evidence that the Plan attempted to obtain the medical 
records. Without this information we are unable to verify that the claim was denied correctly. Therefore, we 
decided that the Plan has to pay for the laboratory services (87481, 87798) provided on October 27, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service August 3, 
2022. 
 You asked the Plan to pay for procedure code 85060. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this service is not payable as it was not provided to a 
hospital inpatient. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85060 have not been met. Specifically, the record shows that this service was 
furnished to an enrollee in an office or non-hospital (Place of Service code 11) setting. Therefore, we decided 
that the Plan does not have to pay for procedure code 85060 billed for date of service August 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a pneumatic compression device used after surgery on 
December 2, 2022. 
 
You asked the Plan to pay for  a pneumatic compression device. You say that this was medically necessary to 
prevent stroke after the surgery. The Plan denied your request. The Plan says no separate payment can be made 
for this item.  
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for  a pneumatic compression device used after surgery on December 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits.  
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider.  Therefore, we decided that the Plan does not have 
to pay for dental services provided on February 2, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on October 26, 2021, 
through November 01, 2021, and billed with diagnosis code A41.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis of A41.9 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of A41.9. 
 
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 code 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 documentation does not support the secondary diagnosis of 
A41.9, Sepsis. Our physician reviewer found the member did not meet Sepsis 3 criteria. There was insufficient 
evidence of the member having a dysregulated response to infection leading to organ failure. Therefore, the 
code, A41.9 (sepsis), is not supported in the documentation.  
 
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 October 26, 2021, through November 01, 2021, and billed with 
diagnosis code A41.9.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay or the OralCDx Brush Test provided on September 26, 2022. 
 
You asked the Plan to pay or the OralCDx Brush Test. You say that the tested were performed as ordered by 
the referring physician. The Plan denied your request. The Plan says that this claim is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case medical records are needed to review the medical necessity of this 
testing. Only the lab report was provided. There is no evidence that the Plan attempted to obtain the medical 
records. Without this information we are unable to verify that the claim was denied correctly. Therefore, we 
decided that the Plan has to pay or the OralCDx Brush Test provided on September 26, 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 pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the Vest System is medically necessary treatment 
for severe chronic bronchitis with coexisting emphysema and frequent lung infections and inability to clear 
retained pulmonary secretions. The Plan denied your request. The Plan says the requested device is not 
medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested HFCWOD is not medically necessary. Our physician reviewer found the provided documentation 
does not support that the enrollee has a diagnosis of cystic fibrosis, neuromuscular disease, or bronchiectasis. 
Therefore, the reviewer found that the requested HFCWOD is not medically reasonable or 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 a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services rendered on December 6, 2022. 
 
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 that anesthesia codes are paid to anesthesia providers only. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that anesthesia codes are paid to anesthesia providers only; 
however, the billing provider is an anesthesiology assistant. The Plan has not provided any documentation or 
binding Medicare rules to support that the services are not covered. Therefore, we decided that the Plan has to 
pay for the anesthesia services rendered on December 6, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on November 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the payment for 
this service is included in the fee for the procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the payment for this service is included in the fee for the 
procedure. However, the Plan has not provided documentation of another service billed on the same date. 
Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the 
Plan has to pay for the services provided on November 17, 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 pre-approve the Transcutaneous Electrical Nerve Stimulators 
(TENS) supplies (A4595), provided o November 12, 2022. 
 
You asked the Plan to pre-approve the TENS supplies. You say that the item was medically necessary. The 
Plan denied your request. The Plan says the item was not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS supplies have not been met. Specifically, the documentation submitted indicates the 
TENS unit was ordered for muscular dystrophy which is not a covered indication. Because the TENS unit was 
ordered for a non-covered indication, the supplies are not medically necessary. Therefore, we decided that the 
Plan does not have to pre-approve the Transcutaneous Electrical Nerve Stimulators (TENS) supplies (A4595), 
provided o November 12, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0249 billed for April 18, 2022, and May 2, 2022. 
 
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 that the billing exceeds the maximum allowed units. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that code G0249 exceeds the maximum allowed units; however, 
there are no binding Medicare rules presented to support this determination. The transmittal referenced by the 
Plan is not germane to the services at issue. The Plan has not provided any documentation to support that code 
G0249 is not payable as billed. Therefore, we decided that the Plan has to pay for procedure code G0249 billed 
for April 18, 2022, and May 2, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70360, 96372) provided on November 23, 
2022. 
 
You asked the Plan to pay for the services. 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 STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service.  
 We looked at the file and Medicare rules. In this case, codes 70360 and 96372 are assigned status indicator Q1. 
Since code 99284 was billed on the same claim and assigned status indicator V, code 70360 and 96372 are 
considered packaged and are not separately payable. 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 (70360, 96372) provided on November 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services, dental services, and additional 
services provided on March 10, 2022, through May 2, 2022. 
 
You asked the Plan to pay for the emergency services, dental services, and additional services. You say that the 
services should be covered. The Plan denied your request. The Plan says this cost sharing was charged 
correctly, dental services must be obtained in-network, and an itemized bill was not provided. 
 
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 you must pay a $120 
copayment for urgently needed services. The provider, supplier, or beneficiary, as appropriate, must furnish to 
the intermediary or carrier sufficient information to determine whether payment is due and the amount of 
payment. 
 
You have been asked to pay a $120 copayment for the emergency services, dental services, and additional 
services. This item/service falls within the urgently needed services 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. The record shows you received the requested 
dental services from an out-of-network provider. Though the Plan offers a dental benefit in excess of Medicare 
coverage, the requested items or services are not covered under this benefit when received from an out-of-
network provider.  There is insufficient information in the record to determine if Medicare rules for coverage of 
the additional services have been met, as no itemized bill was submitted. Therefore, we decided that the Plan 
does not have to pay for the emergency services, dental services, and additional services provided on March 10, 
2022, through May 2, 2022.