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

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that you have severe back pain. The Plan 
denied your request. The Plan says this procedure is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes and no facet 
joint syndrome or foraminal stenosis. Also, the cause of back pain is not clear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 19, 2023, to 
January 17, 2023. 
 You asked the Plan to pay for the home health services. You say that other claims have been paid and this one 
was denied for no reason. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 19, 2022. The NOA was not received by the Plan until January 
23, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from December 19, 2023, to January 17, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs physical therapy otherwise they 
will be bed-ridden. The Plan denied your request. The Plan says a SNF admission is 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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 8, 2022, to 
November 19, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis code A41.9, described as 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 documentation does not support the billed code. 
Our physician reviewer found that the enrollee is a 61-year-old female who presented with nausea, vomiting, 
and altered mental status following 4 days of being treated for urinary tract infection. She was not responding 
to verbal stimuli. She had hypotension; however, it was documented that this could be due to medication 
effects given during a scope procedure and she also has a history of borderline hypotension at baseline. 
Creatinine was elevated which was mentioned in the documentation as likely due to dehydration and improved 
with fluids. Computed tomography revealed evidence of mass suggestive of malignancy. She was started on 
antibiotics but then stopped again due to reaction and didn't need continued antibiotics. She was given 
midodrine and fluids as well as fludrocortisone for continued use after discharge. It was documented that the 
mental status change was likely due to electrolyte disturbances. Platelets were elevated but bilirubin was 
normal. Based on the above, it was not clear that she had an infection that led to a life-threatening dysregulated 
response leading to organ failure as the causes of the abnormalities were all explained and improved even after 
discontinuing the antibiotics. Sepsis 3 criteria was not met. Therefore, there is insufficient support for use of 
the code, A41.9.  
 
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 November 8, 2022, to November 19, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power operated vehicle (POV) 
(scooter) (K0806). 
 
You asked the Plan to pre-approve a scooter. You say that you are an amputee and cannot walk distances. The 
Plan denied your request. The Plan says the notes do not show that a powered operated vehicle (scooter) is 
appropriate for you. 
 
The Plan must follow Medicare rules. Medicare rules say that if a group 2 POV, such as code K0806, is 
provided it will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Specifically, a group 2 standard power operated vehicle (scooter) 
(K0806) exceeds the functionality of use in the home. Based on this information, we decided that Medicare 
rules for coverage of a scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 2 standard power operated vehicle (POV) (scooter) (K0806).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zolpidem tablets. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. 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 Zolpidem tablets.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service November 4, 
2022.  
 
You asked the Plan to pay for procedure code 99232. You say that this is a separately payable service. The Plan 
denied your request. The Plan says payment for code 99232 is bundled into payment for code 99233. 
 
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 99232 is a column II code to column I code 99233 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99232 billed for date of service November 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rotary wing air transport and rotary wing air mileage 
provided on February 3, 2023. 
 
You asked the Plan to pay for the rotary wing air transport and rotary wing air mileage. You say that you are 
appealing the denial of services and requesting payment. The Plan denied your request. The Plan says you did 
not provide any information and we were unable to obtain the records from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that 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.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the rotary wing air transport and rotary 
wing air mileage  have been met. There were no medical records provided. Without this necessary information, 
we are unable to determine whether the criteria for coverage have been met and whether payment is due. The 
Plan has shown that they made reasonable attempts to obtain this necessary information. Therefore, we decided 
that the Plan does not have to pay for rotary wing air transport and rotary wing air mileage provided on 
February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64491-RT-59 billed for date of service July 
8, 2022.  
 You asked the Plan to pay for procedure code 64491-RT-59. You say that you have provided medical records 
to support payment. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64491-RT-59 is 1. The MAI value for this code is 2. You billed 2 units of 
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64491-RT-59 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64491-RT-59 billed for date of service July 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service December 6, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the diagnosis will support each procedure 
performed. The Plan denied your request. The Plan says an appropriate modifier was not billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99284 was billed with minor procedure code 10061. Code 99284 was not billed with a 
modifier to indicate the service was separately identifiable. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99284 billed for date of service December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to apply a $50 copayment for D4910. We decided that the Plan does not have to 
pay for D0120, D1208, or D1999.  
 
You asked the Plan to pay for periodontal maintenance (D4910), a periodic oral evaluation (D0120), topical 
application of fluoride (D1208), and an unspecified preventative procedure (D1999), provided on February 15, 
2023. You say that  The Plan says that   
We decided that the Plan has to apply a $50 copayment towards D4910.  
 
There is a $50 copayment for periodontal maintenance. Therefore, we decided that the Plan has to apply a 
copayment for D4910.  
 
We also decided that the Plan does not have to pay for D0120, D1208, or D1999. 
 
The Plan does not cover dental services D0120 or D1999. D1208 is a covered benefit for children under 19 
years old. Therefore, we decided that the Plan does not have to pay for D0120, D1999, or D1208. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 25, 2022, to 
September 23, 2022. 
 You asked the Plan to pay for the home health services. You say that the NOA is on file with the Plan. The 
Plan denied your request. The Plan says a valid NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 27, 2022. A valid NOA has not been received by the Plan. As more 
than 30 days passed since the timely filing date, no payment can be made on this claim. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from August 25, 2022, to September 
23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 82306, 82607 and 82746 
provided December 7, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you were waiting for diagnosis codes from 
the referring provider, which were received late. Please reprocess your claim for payment consideration. The 
Plan denied your request. The Plan says the claim was submitted past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory service was not filed until February 23, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded as 82306, 82607 and 82746 
provided December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87653 and 87481 billed for date of service 
October 28, 2022. 
 
You asked the Plan to pay for procedure codes 87653 and 87481. The Plan denied your request. The Plan says 
payment for codes 87653 and 87481 is bundled into payment for code 878001. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
In this case, we have confirmed that codes 87653 and 87481 are column II codes to column I code 87801. The 
codes at issue have 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 codes 87653 and 87481 billed for date of service October 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of implantable loop recorder (ILR). You say that insertion of 
implantable loop recorder (ILR) is medically necessary. The Plan denied your request. The Plan says the 
member is not noted in cardiology visits to have worn an external Holter monitor or to have fainting episodes. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 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 insertion of implantable loop recorder 
(ILR). Our reviewer says that the requested insertion of implantable loop recorder is not considered medically 
necessary in this case. Our physician reviewer found that the enrollee has no history of atrial fibrillation, nor 
were any significant cardiac arrhythmias noted on electrocardiogram (ECG) monitoring. A recent randomized 
clinical trial found that continuous monitoring for atrial fibrillation with an ILR (followed by treatment with 
oral anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing stroke or 
systemic embolism among patients at high risk of stroke but without a known prior history of atrial fibrillation. 
At this time, insertion of an ILR would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of implantable loop recorder (ILR)  have not been met. Therefore, we 
decided that the Plan does not have to pre-approve insertion of implantable loop recorder (ILR).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain/ceramic retainer crowns for teeth number 20, 
22, 23, 26, and 27 (D6740 x 5) and porcelain/ceramic pontics for teeth number 24 and 25 (D6245 x 2). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested dental items are not medically 
necessary.  
 
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 Plan covers these dental 
items when medically necessary and reasonable.  
 
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 these dental items.   
 
Our reviewer says that you do not meet criteria for coverage of the requested dental items. Our physician 
reviewer found that a review of the documentation indicates that the bone support for teeth number 23 and 26 is 
less than 50% and there are additional teeth missing in the left posterior lower jaw. A removable appliance 
would be the alternative for the replacement of the missing teeth. The documentation provided does not meet 
the criteria for coverage of a fixed bridge replacing missing teeth number 24 and 25. 
 
We looked at this physician's review, the file, and the Plans rules. Based on this information, we decided that 
the Plan's rules for coverage of these dental items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve porcelain/ceramic retainer crowns for teeth number 20, 22, 23, 26, and 27 (D6740 x 5) 
and porcelain/ceramic pontics for teeth number 24 and 25 (D6245 x 2).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the x-rays provided on October 27, 2022
You asked the Plan to waive the copay for the x-rays. You say that you were charged two times for the x-ray
services on this date. 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 $50
copay for each Medicare-covered X-ray.
You have been asked to pay a $50 copay for the x-rays. This item/service falls within the Medicare-covered Xray
benefit category. The file indicates you had two (2) x-rays on this date of service. This means that you have
been asked to pay less than the correct amount based on your contract with the Plan, as they were entitled to
charge a copay for each x-ray performed.
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 copay for the x-rays provided on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95885 and 95907 billed for date of service 
December 13, 2022. 
 
You asked the Plan to pay for procedure codes 95885 and 95907. You say that medical records were provided. 
The Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 95885 and 95907. This means there is 
both a professional and technical component for the CPT codes. In this case, an appropriate modifier to indicate 
the professional component has not been billed with the CPT codes. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 95885 and 95907 billed for date of service December 13, 2022.