Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 28, 2022, to 
September 2, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says that the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented to the emergency department (ED) on August 28, 2022 from a skilled 
nursing facility with rapid heart rate. The evaluation revealed atrial fibrillation with rapid ventricular rate. She 
was hemodynamically stable and attempts for rate control were unsuccessful in the ED. The records show that, 
at the time of the inpatient admission, the admitting physician reasonably expected that the enrollee's necessary 
hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 28, 2022, to September 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service September 
13, 2022.  
You asked the Plan to pay for procedure code 88360. 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 88360 is 6. The MAI value for this code is 3. You billed 12 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88360 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88360 billed for date of service September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingivectomy (D4212). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental 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. 
 
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 pre-approve a 
gingivectomy (D4212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided on November 21, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you went to the dentist and 
asked them if your insurance would pay for the services. You also say that the dentist office advised yes, and 
they only do what insurance would pay. The Plan denied your request. The Plan says your benefit for the 
comprehensive oral evaluation has already been exhausted. 

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 comprehensive oral evaluation was exhausted on date of service September 28, 
2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or 
established patient (D0150) provided on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99497 billed for date of service September 2, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 99497 is bundled into 
payment for code 99223. 
 
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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service September 2, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service November 4, 
2022. 
 
You asked the Plan to pay for procedure code 20930. The Plan denied your request. The Plan says procedure 
code 20930 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service November 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service August 3, 
2022. 
 You asked the Plan to pay for procedure code 99497. The Plan denied your request. The Plan says payment for 
code 99497 is bundled into payment for code 99223. 
 
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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service August 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
December 6, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure.  
 
We looked at the file and Medicare rules. The panel provided in this case was not billed with a single code as 
required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 
panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase 
chain reaction (PCR) panel provided on December 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found on April 24, 2023, you were walking more than 150 feet SBA and toileting at SBA 
and lower body dressing. You have reached a level of function that allows you to restore or maintain function 
with repetitive exercise and support from non-skilled personnel. Per chapter 8, continued daily skilled therapy 
is not medically necessary. No daily skilled nursing needs were provided or indicated. 
 
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 SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you are requesting reconsideration because 
you have a hard time getting around in your home. You cannot use a walker or wheelchair. It is unclear if you 
have had a home evaluation and that the device would be able to be used in the home, including adequate space 
to turn the device. The Plan denied your request. The Plan says the request is not medically necessary because 
the records show you do not have documentation that supports that your mobility limitation is impairing your 
ability to participate in one or more MRADLs or that another properly fitted device was inadequate. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  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 power scooter. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found you have a bilateral foot drop. The 
medical records do not provide functional data sufficient to determine the need for a power wheelchair. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was residing at the SNF for custodial care when he was diagnosed with a 
COVID-19 infection. He was treated supportively for the associated symptoms. He remains medically stable 
and does not require any skilled nursing or skilled therapy services. He is noted to be at or near his functional 
and medical baseline. He does not require skilled nursing or skilled therapy on a daily basis. As a practical 
matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on November 
22, 2022. 
 
You asked the Plan to pay for the bacterial urine culture. You say that this service was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted 
with a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 87086. Any codes which are not listed are considered not medically necessary for 
code 87086. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine culture have not been met. Specifically, this claim was submitted with a diagnosis code which is not among those codes listed as medically necessary and appropriate for this service. Therefore, we 
decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on November 22, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the opioid treatment services billed for date of service December 26, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the provider is certified. The Plan denied your 
request. The Plan says that the code must be billed on the facility claim. 
 
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. 
 
We looked at the file and the rules. The Plan rationale incorrectly states that this claim was submitted by a 
physician rather than the OTP facility. The claim submitted shows that the billing provider is the OTP facility. 
This was submitted on a professional claim which is allowed according to the billing guidelines. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request.  Therefore, we decided that the Plan has to pay for the opioid treatment services billed for 
date of service December 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. You say the continuity of care offered at the IRF will give the enrollee the best opportunity 
to improve function and return to baseline. The Plan denied your request. The Plan says the request for an IRF 
admission is not medically necessary at this time. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary and appropriate. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service July 1, 
2022, to July 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service July 1, 2022, to July 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continuation of SNF care does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found at the time of admission, the enrollee required skilled rehab services 
to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of the last 
covered day, the enrollee did not require any skilled nursing or rehab services on a daily basis. He was not 
expected to make measurable gains within a reasonable and predictable period of time or require skilled 
therapy to prevent deterioration with mobility or self-care tasks. The enrollee did not require skilled therapy to 
establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any 
skilled services on an inpatient basis, at a skilled level of care as of April 27, 2023. The enrollee did not have 
any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee's function 
was at or near his prior level of function and he could be discharged to a lower level of care for further services. 
As of April 27, 2023, the enrollee required custodial services. The denial for further inpatient skilled care 
beyond the last covered day is upheld. 
 
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 SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.