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

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service December 8, 
2022.  
 
You asked the Plan to pay for procedure code 88341. 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 88341 is 13. The MAI value for this code is 3. You billed 18 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 88341 have not been met.  Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service December 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says items related to travel, convenience, or luxury are not covered. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 concentrator Our reviewer says that 
the requested item is not medically reasonable or necessary. Our physician reviewer found this is being 
requested for travel, which is not covered by Medicare. There is no documentation that SpO2 can be 
maintained above 91% using an oxygen conserving device and a flow rate of 1 to 4 L/min.  This is a Medicare 
requirement. 
 
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 concentrator have not been met.  Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power option 
(K0856), a power seating system (E1002), and accessories (E2359, E2620, E2605, E0955, E1028, K0108, 
E1028, E2331). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with a single power option, a power seating 
system, and accessories . You say that this is medically necessary. The Plan denied your request. The Plan says 
the requirements for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a group three power wheelchair with a single power 
option is covered if the beneficiary either requires a drive control interface other than a hand or chin-operated standard proportional joystick or  meets coverage criteria for a power tilt or a power recline seating system and 
the system is being used on the wheelchair.  
 
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 group 3 power wheelchair with a 
single power option, a power seating system, and accessories . Our reviewer says that the specific requested 
power wheelchair is not medically necessary. Our physician reviewer found the records do not indicate that the 
enrollee has any pressure injuries, requires intermittent catheterization of the bladder, or has spasticity that 
would necessitate power tilt or recline. The records also do not show the enrollee requires a drive control 
interface other than a hand or chin-operated standard proportional joystick. 
 
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 group 3 power wheelchair with a single power option, a power seating system, 
and accessories  have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair with a single power option (K0856), a power seating system (E1002), and accessories 
(E2359, E2620, E2605, E0955, E1028, K0108, E1028, E2331).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 7, 2022, billed 
with codes 81225, 81227, 81231, 81232, 81238, 81291, 81306 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 
November 7, 2022, billed with codes 81225, 81227, 81231, 81232, 81238, 81291, 81306 and 81335.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: 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 are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says your request for an IRF admission 
does not meet the requirements for approval.  
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), the intraoral radiographic images (D0220 and D0230), and the periodontal maintenance (D4910), provided by an out-of-network provider on January 13, 2023, March 10, 2023, and March 16, 2023.

You asked the Plan to pay more for the dental services. You say that the dental services should be covered at 100% and you do not think you should have been billed for them. The Plan denied your request. The Plan says the correct cost share was applied for the dental services that were received from the out-of-network provider.

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 50% of the total allowed amount for all routine (preventive & comprehensive) dental services when you get these services from an out-of-network provider.

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.

On January 13, 2023, the total allowed amount for the limited oral evaluation (D0140) was $86 with a coinsurance amount of $43 ($86 allowed x 50% coinsurance). The total allowed amount for the intraoral radiographic image (D0220) was $32 with a coinsurance amount of $16 ($32 allowed x 50% coinsurance). The total allowed amount for the intraoral radiographic image (D0230) was $27 with a coinsurance amount of $13.50 ($27 allowed x 50% coinsurance). The total coinsurance amount for January 13, 2023, was $72.50 ($43 coinsurance + $16 coinsurance + $13.50 coinsurance). On March 10, 2023, the total allowed amount for the periodontal maintenance (D4910) was $199 with a coinsurance of $99.50 ($199 allowed x 50% coinsurance). On March 16, 2023, the total allowed amount for the limited oral evaluation (D0140) was $86 with a coinsurance of $43 ($86 allowed x 50% coinsurance). The total coinsurance amount for all dates of service was $215 ($72.50 coinsurance + $99.50 coinsurance + $43 coinsurance). You have been asked to pay a 50% coinsurance for the dental services provided by an out-of-network provider. This item/service falls within the dental 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. Therefore, we decided that the Plan does not have to pay more for a limited oral evaluation (D0140), the intraoral radiographic images (D0220 and D0230), and the periodontal maintenance (D4910), provided by an out-of-network provider on January 13, 2023, March 10, 2023, and March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation and image guided radiation treatment (IGRT) 
with 5 fractions (G6002, G6012, G6013, G6014). 
 
You asked the Plan to pre-approve radiation and IGRT. You say that the additional treatments are medically 
necessary. The Plan denied your request. The Plan says using more than 10 treatments and imaging's exceeds 
the medical need for treating the enrollee's cancer and condition. Medicare would not cover any more 
treatments than this. They would not be medically necessary. 
 
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 radiation and IGRT. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found this case is a bit complicated in that three sites are being treated with 5 fractions, so 
the treatment itself is in accordance with accepted standards as outlined above. The issue is treating the lesions 
sequentially such that instead of 5 fractions of treatment (treating all sites in 5 days) or 10 fractions (treating 2 
sites in 5 days than 1 site in 5 days) the request is for 15 treatments. This really becomes a billing issue as 
opposed to medical necessity issue, as the treatment is standard and medically necessary.  As the insurers 
standard is to cover the treatment of bone metastases in one course to not exceed 10 fractions, the decision is 
unfavorable for the additional 5 fractions (and would have been unfavorable for >5 fractions without the appeal 
addressing why this would be 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 radiation and IGRT have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiation and image guided radiation treatment (IGRT) with 5 fractions (G6002, 
G6012, G6013, G6014).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95955, 95937, 95908 and 95927 billed for 
date of service February 10, 2021. 
 
You asked the Plan to pay for procedure codes 95955, 95937, 95908 and 95927. You say that these services are 
supported as billed. The Plan denied your request. The Plan says these services are not supported in the medical 
records provided. 
 
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 95955, 95937, 95908 and 95927. Our 
reviewer says that the documentation provided does not support the reporting of these codes. Our reviewer 
found that for the procedure described, the provider uses electroencephalographic monitoring of a patient 
during non-intracranial surgery like cardiac surgery or carotid stenting. There is a more appropriate code than 
95955 to report for service provided. In addition, the report does not include documentation of neuromuscular 
junction testing (95937) or somatosensory evoked potentials (SSEP) stimulation of any/all peripheral nerves or 
skin sites, recording from the central nervous system, in the trunk or head (95927). Other procedures were 
performed which are not appropriate to report with these codes. The report also does not include documentation 
of nerve conduction studies (95908). Procedure report describes pedicle screw stimulation, which would not be 
reported with nerve conduction (sensory conduction, motor conduction, with or without an F wave test, or an 
H-reflex test). The codes reported 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 procedure codes 95955, 95937, 95908 and 95927 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 95955, 95937, 95908 and 95927 billed for 
date of service February 10, 2021.
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 are appealing the denial. The Plan denied your 
request. The Plan says that you do not meet Medicare criteria for admission. 
 
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. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automobile rack. 
 
You asked the Plan to pre-approve an automobile rack. You say that you were given a scooter and you need a 
rack for your car in order to take it places. The Plan denied your request. The Plan says an automobile rack is 
not a covered benefit. 
 
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 pre-approve an automobile rack.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets criteria for admission. The Plan 
denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromonitoring services provided on March 1, 2021, 
billed with codes 95908 and 95955. 
 
You asked the Plan to pay for the services as billed. You say that the services should be paid. The Plan denied 
your request. The Plan says the two denied codes are 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 95908 is nerve conduction studies; 3-4 studies. The 
definition of code 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). 
 
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 as billed. Our reviewer says that the billed 
services are not supported.  Our reviewer found the documentation does not support nerve conduction studies, 
but pedicle screw stimulation. This service would not be reported with nerve conduction study procedure 
codes, as these tests are not the same. In regard to code 95955, there is a more appropriate code to report as, the 
documentation does not support EEG during non-intracranial surgery like cardiac surgery or carotid stenting.   
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the neuromonitoring services provided on March 1, 2021, billed with codes 95908 and 
95955.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled care. 
 
You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the requested home health agency does 
not participate in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the requested provider is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve home health skilled care.