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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 19, 2022, to July 
28, 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 J15.6 is 
supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says J15.6 is not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
In this case, you billed the inpatient services provided with secondary diagnosis J15.6, defined as pneumonia 
due to other gram-negative bacteria. 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 J15.6 is not supported in the 
documentation. Our physician reviewer found the enrollee is a 70-year-old who was treated in the hospital. 
They presented with shortness of breath, a respiratory rate of 22, oxygen saturation of 97% on room air, and 
without respiratory distress. They were found to have hemoglobin of 6.5. They had no fever and no 
leukocytosis. Chest x-ray did not show evidence of pneumonia, and chest examination included no objective 
evidence of pneumonia.  
 
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 July 19, 2022, to July 28, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 65865 rendered on June 27, 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 provider did not bill as required by Medicare coding regulations. 
 
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 65865 is "Severing adhesions of anterior segment of eye, 
incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae." 
 
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 procedure report does not 
support this procedure was a distinct procedure from the cataract extraction. CPT 65865 may be appropriate to unbundle. The operative report must clearly identify the two separate procedures. For example, surgeon may 
need to perform an intraoperative gonioscopy to visualize if the synechialysis is necessary after the cataract 
removal has been performed. 
 
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 code 65865 rendered on June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service July 28, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the procedure codes were medically necessary.  
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  The file shows that a wound panel was provided. We looked at the file and Medicare rules. The documentation 
supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, 
multiple methodologies, or multiple kits were used in this case. As such, a single code with one unit of service 
should be used. Based on this information, we decided that Medicare rules for coverage of the testing panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the panel testing billed for date 
of service July 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial dentures (D5214). 
 
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 you do 
not meet the clinical requirements to be approved. 
 
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 the dental 
services when the services are 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 the dental services. Our physician 
reviewer found at the present time; it could not be determined that the condition of the mouth would support a 
partial denture.  The requested treatment cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve mandibular partial dentures (D5214).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97750 (6 units) provided on August 8, 2023. 
 
You asked the Plan to pay for procedure code 97750 (6 units). You say that these services were necessary and 
are supported in the medical record. The Plan denied your request. The Plan says these services are not 
supported as 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 97750 is physical performance test or measurement (e.g., 
musculoskeletal, functional capacity), with written report, each 15 minutes. 
 
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 code 97750 (6 units). Our reviewer says that these services are not supported as billed. Our reviewer found that the medical record includes insufficient 
documentation to verify these services were performed for the number of units billed. This procedure code 
represents a timed procedure, each measurement should include time spent. Also, the procedure report does not 
include the servicing providers name and signature.  
 
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 code 97750 (6 units) have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 97750 (6 units) provided on August 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77427 rendered on August 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 billing entities must indicate on each claim the number of fractions for which payment is sought. 
 
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 77427 is "Radiation treatment management, 5 
treatments." 
 
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 include insufficient 
documentation to support the radiation treatment billed. CPT code 77427 is reported once for every five fractions or treatment sessions regardless of the actual time period in which the services are furnished. 
 
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 code 77427 rendered on August 3, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracranial Doppler study provided on February 28, 
2023, billed with code 93882. 
 
You asked the Plan to pay for the extracranial Doppler study. You say that this claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis code reported is not valid for the 
service at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that the local MAC has indicated that diagnosis code 
I63.9 does not support medical necessity for code 93882.  Therefore, we decided that the Plan does not have to 
pay for the extracranial Doppler study provided on February 28, 2023, billed with code 93882.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional units of Truxima. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says new 
labs are needed due to the enrollee's condition.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
The file shows that 300 units of Truxima were requested. The Plan has agreed to approve 100 units. 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 services. Our physician reviewer found that the 
enrollee has a diagnosis of rheumatoid arthritis. The record provided suggests that the enrollee has recent 
Hepatitis B infection that has not yet been evaluated. The FDA has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation.  The record provided is insufficient to establish that the requested service is safe for the enrollee' condition. The 
record provided does not establish the medical necessity and reasonableness of additional units. The elements 
of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 additional units of Truxima.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274) and prophylaxis (D1110) provided on July 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that on the date of service the provider was in-
network with the Plan. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274) and prophylaxis (D1110) provided on 
July 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced pneumatic compression device to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an advanced pneumatic compression device 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 
an advanced pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 3, 2023, billed with 
procedure codes 93458-26 and 99152. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 93458-26 and 99152 is catheter placement in coronary 
artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging 
supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left 
ventriculography, when performed, and moderate sedation services provided by the same physician or other 
qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the medical record does not include a 
procedure report to support service billed, and therefore 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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on July 3, 2023, billed with procedure codes 
93458-26 and 99152.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J3490, defined as unclassified drugs, billed for date of 
service September 15, 2023. 
 You asked the Plan to pay for J3490. You say that J3490 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says J3490 is denied because payment for this code is 
included in payment for code 62321 that was billed on the same claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of local anesthesia is included in the 
payment for the chemotherapy administration or nonchemotherapy injection and infusion service. 
 
We looked at the file and Medicare rules. In this case, the record indicates that J3490 was reported with 
National Drug Code (NDC) 00409115902, for Bupivacaine. Bupivacaine is a local anesthetic. The record 
documents that the Bupivacaine was administered to facilitate the therapeutic injection services coded as 
62321. Medicare rules state that if performed to facilitate an infusion, injection, or hydration, the use of local 
anesthesia is not separately billable. Based on this information, we decided that Medicare rules for coverage of 
J3490 have not been met. Therefore, we decided that the Plan does not have to pay for code J3490, defined as 
unclassified drugs, billed for date of service September 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup (D2950) provided on 
July 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that on the date of service the provider was in-
network with the Plan. The Plan denied your request. The Plan says these services are either not covered 
benefits or the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Additionally, D2950 is not covered under any 
circumstance. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and core buildup 
(D2950) provided on July 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopy, diagnostic, whipple procedure to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a laparoscopy, diagnostic, whipple procedure. You say that this surgical 
oncologist would provide a better outcome because the Plan does not have adequate network providers. The 
Plan denied your request. The Plan says the requested service not urgent or emergent and is available in-
network. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 laparoscopy, diagnostic, whipple procedure. Our reviewer says that the 
service is not medically necessary to be provided OON. Our physician reviewer found that there is a 
hepatobiliary surgeon in-network who can perform the requested service. Thus, it is not medically necessary to 
have the service provided OON. 
 
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 laparoscopy, diagnostic, whipple procedure have not been met.  
 
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 a laparoscopy, diagnostic, whipple procedure. 
Therefore, we decided that the Plan does not have to pre-approve a laparoscopy, diagnostic, whipple procedure 
to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor (A4239) provided on July 10, 2023. 
 
You asked the Plan to pay for a CGM sensor. You say that you have billed the items at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee had CGM sensors provided by another supplier at the time a CGM sensor was 
received. CGM sensors provided by another supplier serve the same purpose as the CGM sensor at issue. Therefore, we decided that the Plan does not have to pay for a Freestyle Libre 2 continuous glucose monitor 
(CGM) sensor (A4239) provided on July 10, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for psychotherapy provided on January 04, 
2023, to August 09, 2023. 
 
You asked the Plan to waive the coinsurance for psychotherapy. You say that the full Medicare amount should 
be paid. 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 50% 
coinsurance for outpatient mental health care. 
 
You have been asked to pay 50% coinsurance for psychotherapy. This item/service falls within the outpatient 
mental health care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for psychotherapy 
provided on January 04, 2023, to August 09, 2023.