Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital bed provided on August 4, 2023. 
 You asked the Plan to pay for the hospital bed. You say that you have provided medical records showing that 
the enrollee required this bed following surgery. The Plan denied your request. The Plan says the diagnosis 
code at issue is not appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code M41.50. This 
code is not an appropriate primary diagnosis as the code has a Code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for the hospital bed provided on August 4, 
2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (81401) provided on May 25, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that in order to identify 
the analyte being tested under the code submitted, an appropriate Claim Designation code or Abbreviated Gene 
Name must be submitted on the 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that in order to identify the analyte being tested under the code 
submitted, an appropriate Claim Designation code or Abbreviated Gene Name must be submitted on the claim. 
We find that no Medicare guideline was presented to support the Plan's denial in this case. The provider 
reported another molecular pathology procedure, which was approved. Without supporting documentation, the 
Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the lab services 
(81401) provided on May 25, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 this procedure would benefit the 
enrollee. The Plan denied your request. The Plan says this is not a covered procedure. 
 
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 (MRI) showing only modic changes without 
facet joint disease or stenosis. The cause of pain is also 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99223 billed for date of service March 27, 
2023.  
 
You asked the Plan to pay for procedure code 99223. You say that this service was medically necessary. 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 99223 is 1. The MAI value for this code is 3. You billed 2 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 99223 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99223 billed for date of service March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies provided on June 30, 2023. 
 
You asked the Plan to pay for the medical supplies. You say that the enrollee's hospice benefits were revoked 
on June 5, 2023. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 5, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for medical supplies provided 
on June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided on May 30, 2023. 
 
You asked the Plan to pay for an ankle-foot orthosis. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The provided medical records do not address the item at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for an ankle-foot orthosis (L1971) provided on May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a transcutaneous electrical nerve stimulation (TENS) device. 
 
You asked the Plan to pre-approve a TENS device. You say that you would like a replacement for your 
outdated TENS unit you have had since September 7, 2005. The Plan denied your request. The Plan says that 
while chronic back pain is a covered diagnosis for this device, you are not currently part of any clinical trial in 
order to qualify for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a TENS device. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found you have chronic back pain with relief from a TENS unit that you have had since 2005. The 
continuation of the TENS unit is thus medically necessary, and you have provided documentation of your 
chronic back pain to qualify for criteria outlined for coverage. 
 
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 TENS device have been met. Therefore, we decided that the Plan has to pre-
approve a transcutaneous electrical nerve stimulation (TENS) device.  
 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service July 27, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We asked our physician 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 99285. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee presented with asymptomatic hypertension. Screening exam performed to rule out hypertensive emergency. The enrollee was given IV 
antihypertensives. The appropriate history and physical exam performed. The documentation does not support 
high level of medical decision making. Therefore, code 99285 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 for date of service July 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service August 17, 2023. 
 You asked the Plan to pay for the lab services. You say that this testing is covered by Medicare, and it should 
be paid. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier in the proper location on the claim. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported in the correct area of the claim.  Specifically, the rules require that this Z-code be reported in the 
SV101-7 (5010A1-837P) or SV202-7 (5010A1-837I) claim line detail field. In this case, you placed the Z code 
in 24-S (the remarks, line-level) field.  This is not the proper location for this code. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for lab services billed for date of service August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy. 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the requested service is not 
covered by Medicare or the Health Plan. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found daily image-guided radiation therapy (IGRT) which would not be 
furnished in accordance with accepted standards of medical practice." 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99285 billed for May 21, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that procedure code 99285 is 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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 
3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or 
mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat 
to life or physiologic function. 
 
We asked our physician 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 these services. Our reviewer says that procedure code 
99285 is supported. Our reviewer found the enrollee, with multiple cardiac risk factors, presented to the 
emergency department with chest pain. The work up included an electrocardiogram (EKG), labs, and imaging. 
The records support that the comprehensive history, comprehensive examination, and medical decision making 
of high complexity were present. Code 99285 is therefore supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 99285 billed for May 21, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 12, 2023, to 
May 11, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that your organization had a change 
in ownership, so you would like an exception for timely filing. The Plan denied your request. The Plan says the 
claim has not been billed with the correct admission date. The admission dates on the NOA and on the claim do 
not match. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 12, 2023, to May 
11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral neurostimulator (PNS) (64555). 
 
You asked the Plan to pre-approve a Sprint PNS. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 a Sprint PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a SPRINT PNS device is experimental for chronic pain. More research is needed. 
 
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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Sprint peripheral neurostimulator (PNS) (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 31 units of code E0570 provided from March 10, 2023, to 
April 9, 2023. 
 
You asked the Plan to pay for 31 units of code E0570. The Plan denied your request. The Plan says the billed 
units are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 31 units of code E0570 Our reviewer says 
that the records do not support 31 units of code E0570. Our physician reviewer found that the provider reported 
medical equipment as a rental (RR per claim) with 31 units. Durable medical equipment being rented should be 
billed with 1 unit per month until the cap is reached.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 31 units of code E0570 have not been met. Therefore, we decided that the Plan 
does not have to pay for 31 units of code E0570 provided from March 10, 2023, to April 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 27, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says criteria for admission to the 
LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee requires tracheostomy and percutaneous endoscopic gastrostomy (PEG) 
care and ongoing physical therapy. There are no services available at the LTACH that the enrollee requires that 
are not available at the health care setting being offered by the Plan. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 18, 2023. 
 
You asked the Plan to pay for the medical services. You say that these services are valid for the Place of 
Service billed. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that J43.8 has an Excludes1 note in relation to J44.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on July 18, 2023.