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

 
We decided that the Plan does not have to pay for procedure codes J0735 and J1170 rendered on February 3, 
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 these codes are not appropriate for the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) J0735: 
 
Injection, clonidine hydrochloride, 1 mg  
HCPCS J1170: 
 
Injection, hydromorphone, up to 4 mg 
 
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 the medical record describes 
Hydromorphone and Clonidine compounded. In this case there is a more appropriate HCPCS code to report for 
these services provided. J0735 and J1170 separately cannot be verified. 
 
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 procedure codes J0735 and J1170 rendered on February 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code A41.51 
rendered from January 17, 2021, to January 23, 2021. 
 
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 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 diagnosis code A41.51 and DRG 871. 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 in this case, there was no clinical or laboratory evidence of sepsis. The review 
has determined that the documentation does not support diagnosis code A41.51. The records more support 
DRG 689.  
 
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 billed with diagnosis code A41.51 rendered from January 17, 2021, to January 
23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 99306 rendered on 
January 6, 2023. 
 You asked the Plan to pay for the additional unit. You say that this should be paid for. The Plan denied your 
request. The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 93306 is "Initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using total time on the date of the encounter for code 
selection, 45 minutes must be met or exceeded." 
 
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 additional unit. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that after a careful review of 
the documentation, evaluation and management services were not found in the medical record.  The 
documentation includes an ECHO report.  Therefore, this procedure and the units cannot be verified. 
 
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 additional unit have not been met. Therefore, we decided that the Plan does 
not have to pay for an additional unit of procedure code 99306 rendered on January 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on January 23, 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 the criteria is not met for payment of CPT 99285, as there was no high/immediate threat to life or 
physiological function. 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that 
there was a highly complex level of decision making. 
 
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 department services (procedure code 99285) rendered on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of procedure codes 95861 and 95868 
rendered on June 23, 2022. 
 You asked the Plan to pay for the additional services. You say that this should be paid for. The Plan denied 
your request. The Plan says the documentation does not support that excess units were provided or medically 
necessary. 
 
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 the denied codes is: 
 
CPT 95861: 
 
Needle electromyography; 2 extremities with or without related paraspinal areas 
 
CPT 95868: 
 
Needle electromyography; cranial nerve supplied muscles, bilateral 
 
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 additional services. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that in terms of CPT 95861, 
the electromyography (EMG) recording was only performed in the bilateral upper extremities. This is reflected 
by the submission of CPT 95861. As EMG recording/measurement in two limbs is "covered" by this CPT code, 
it was not appropriate for a second unit of this CPT code to have been billed. In terms of CPT 95868, the same 
rationale applies. Bilateral recordings/measurements were performed of a cranial nerve innervated muscle. 
However, this CPT code covers bilateral measurements. In as much submission of an extra unit for this CPT 
code is not reflected within the records provided for review. 
 
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 additional services have not been met. Therefore, we decided that the Plan 
does not have to pay for additional units of procedure codes 95861 and 95868 rendered on June 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code A41.9 
rendered from October 24, 2022, to October 25, 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 the DRG was updated, and the determination 
to remove diagnosis code A41.9 (Sepsis unspecified organism) primary diagnosis remains upheld. 
 
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 871. 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 in this case, there was no clinical or laboratory evidence of sepsis. The review has determined that the 
documentation did not support diagnosis code A41.9. The records more support DRG 193.  
 
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 billed with diagnosis code A41.9 rendered from October 24, 2022, to October 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDX- SCC testing provided on January 3, 2023. 
 
You asked the Plan to pay for the DecisionDX- SCC testing. You say that this testing was medically necessary 
and ordered by the patient's doctor. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only those molecular diagnostic tests listed on 
MolDX website www.palmettogba.com/MolDX as covered are reimbursable.  Other testing not listed in this 
registry is excluded from coverage. 
 
In this case, the DecisionDX-SCC testing is listed on the aforementioned website as "Not Covered" with no 
Food and Drug Administration 510K/Premarket Approval number.  There is also no pricing information listed, 
indicating that this test is not covered under the MolDX registry. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DecisionDX- SCC testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the DecisionDX- SCC testing provided on January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
January 4, 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 Current Procedural Terminology (CPT) 99223 remains 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 in this case, the documentation 
doesnt support the CPT code 99223. The documentation available for review does not support the encounter 
included a comprehensive history. 
 
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 initial hospital care (procedure code 99223) rendered on January 4, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a prosthesis/orthosis (L3960, L0457, L1852, L2397) rendered on 
January 26, 2023. 
 
You asked the Plan to pay for the items. You say that this was medically necessary. The Plan denied your 
request. The Plan says that this was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the items. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the physicians various documents provided in the file fully disprove the Plans assertions regarding 
the medical record and satisfy the LCD and Policy Article requirements for coverage of these various braces. 
L0457 is covered because the brace was intended to reduce pain by restricting mobility of the trunk. L1852 and 
L2397 are covered because they were ordered for an ambulatory enrollee. The physician documented knee 
instability as a part of the packet signed 1/29/23. The physician order additionally satisfies all of the criteria for 
all 4 codes. 
 
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 items have been met. Therefore, we decided that the Plan has to pay for a 
prosthesis/orthosis (L3960, L0457, L1852, L2397) rendered on January 26, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from August 20, 2022, to 
September 25, 2022. 
 
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 a line-by-line review of both the itemized bill and the medical records were performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 the medical records do not 
include documentation of a bladder scan, catheterization INF per cent/midline, gait training, occupational 
therapy evaluation, physical therapy evaluation, therapeutic activities, ultrasound guidance for vascular access. 
Although the procedures were documented in the appeal response, they were not documented in the medical records, and correctly denied for denial code B. Additionally, in terms of the denied charges for code K 
(duplicate billing), the itemized bill includes documentation of the denied charges. In this case, the health plan 
states CPAP therapy was reported twice for dates of service 8/26/2022 and September 3, 2022. The itemized 
bill shows this service was billed twice on same date of service. Therefore, the service was denied correctly as 
duplicate.  
 
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 inpatient hospital services rendered from August 20, 2022, to September 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peritoneal dialysis treatments (90960, 90945) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve peritoneal dialysis treatments to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
peritoneal dialysis treatments (90960, 90945) to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn-3. Our reviewer says that 
Gelsyn-3 is not medically necessary. Our physician reviewer found that the enrollee has right knee pain due to 
osteoarthritis of the right knee. Although the provided has recommended viscosupplementation therapy with 
Gel-Syn-3, the enrollee has not trialed two of the preferred viscosupplemental treatments such as Spuratz FX, 
Hyalgan, Euflexxa or Synvisc-One. Also, the documentation does not outline contraindications or reasons these 
medications were not considered or that the plan's additional required drug would likely be less effective or 
likely have adverse effects for the enrollee. Therefore, Gelysn-3 is not approved as the step therapy criteria has 
not been met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LiquaCel Liquid Protein. 
 
You asked the Plan to pre-approve LiquaCel Liquid Protein. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested oral supplement is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve LiquaCel Liquid Protein.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skin cleanser purchased on February 1, 2023. 
 
You asked the Plan to pay for the skin cleanser. You say that the back of the label reads this cleanser can be 
used with or without water, and your doctor recommended it for rosacea and sensitive skin. The Plan denied 
your request. The Plan says this is an ineligible expense under your plan. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and skin 
cleanser is an OTC item. However, your plan offers a supplemental benefit for specific OTC items. Skin 
cleanser is not listed as a covered OTC benefit under the supplemental reimbursement program. Therefore, we 
decided that the Plan does not have to pay for the skin cleanser purchased on February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
treatment is not supported for the enrollee's cancer.  
 
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 requested services. Our physician 
reviewer found that for metastatic disease, SBRT is generally only indicated for those with oligometastatic 
disease or for those undergoing palliation after prior radiation. For this enrollee, the plan is to treat a lung 
metastasis from renal cancer; other sites of metastases (brain and multiple lung lesions) are well-controlled on 
systemic therapy. While SBRT for oligoprogression is an emerging approach it is not standard of care at this 
time. Therefore, the request is not medically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve stereotactic body radiation therapy (SBRT).