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

 
We decided that the Plan does not have to pay for portable diagnostic and visit services provided on March 8, 
2023. 
 
You asked the Plan to pay for portable services. You say that you are the only provider that can perform these 
much-needed services. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a mobile unit is serving an entity for which 
another Place of Service (POS) code already exists, the provider should use the POS code for that entity.  
 
We looked at the file and Medicare rules. This mobile unit was serving a nursing facility. Therefore, the POS 
code 11  indicating an office setting  is not appropriate for this claim. Based on this information, we decided 
that Medicare rules for coverage of portable services have not been met. Therefore, we decided that the Plan 
does not have to pay for portable diagnostic and visit services provided on March 8, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs another week of skilled nursing 
care that is needed after knee surgery. You say the enrollee will not get that level of care at their assisted living. 
The Plan denied your request. The Plan says your request for approval of continued admission to a SNF does 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee 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 and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an excision/lipectomy. 
 
You asked the Plan to pay for an excision/lipectomy. You say that the skin removal was necessary. The Plan 
denied your request. The Plan says this procedure is considered cosmetic. 
 
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 pay for an excision/lipectomy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record provided does not document the presence of intertrigo refractory to 
conservative treatment or functional impairment. 
 
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 excision/lipectomy have not been met. Therefore, we decided that the Plan 
does not have to pay for an excision/lipectomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 16, 2022, 
to November 21, 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 
services and diagnoses listed on this claim were reported appropriately. The Plan denied your request. The Plan 
says the DRG reported for this claim is not supported in the medical record. 
 
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 encephalopathy, unspecified (G93.40). 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 this diagnosis code is not supported in the medical records. Our physician 
reviewer found the enrollee was brought to the emergency department for evaluation of shaking. The enrollee 
and caregiver thought the enrollee was confused, but the enrollee was repeatedly found to be alert and oriented, 
and the encephalopathy work-up was negative. The enrollee did exhibit some memory loss and anxiety 
consistent with dementia and aging. It appears that encephalopathy was ruled out, and that the enrollee likely 
had mild dementia with or without acute delirium. The billing of G93.40 is not supported.  
 
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 16, 2022, to November 21, 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 surgical assistant services (52005 and 44005) provided on 
February 1, 2023. 
 
You asked the Plan to pay for surgical assistant services. You say that these services were necessary and were 
performed by an eligible provider. The Plan denied your request. The Plan says a surgical assistant is not 
necessary or permitted for code 52005, and the payment for code 44005 is included in the payment for code 
50543 reported on the same claim. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 52005. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid.  
 
In addition, 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 44005 is a column II code to column 
I code 50543 with a modifier indicator of 0. The column II code is therefore not payable. Based upon this 
information, we find that Medicare coverage criteria for surgical assistant services have not been met. 
Therefore, we decided that the Plan does not have to pay for surgical assistant services (52005 and 44005) 
provided on February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic tires and tire flat-free upgrades for an 
ultralight wheelchair. 
 
You asked the Plan to pre-approve upgraded tires. You say that you are limited without having this to get out of 
your home. The Plan denied your request. The Plan says these components are primarily for use outside of the 
home so are not covered by Medicare. 
 
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 pneumatic tires and tire flat-free upgrades for an ultralight wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 billed for date of service July 11, 
2022.  
 
You asked the Plan to pay for procedure code G0481. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code G0481 is bundled into payment for code 80307. 
 
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 G0481 
is a column II code to column I code 80307 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 G0481 billed for date of service July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested SI joint RFA is 
considered experimental/investigational in nature due to the wide variety in efficacy reported in the medical 
literature. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87798, and 87461 for date of service 
September 21, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87798, and 87461. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of the XU modifier means unusual Non-
Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the 
main service. 
 
We looked at the file and Medicare rules. Review of the file shows that code 87150 was billed with the XU 
modifier. Code 87150 is included in code 87801. The documentation does not support that the procedure or 
service was distinct or independent from other services performed; therefore, the use of the XU modifier is not 
supported. Code 87798 was billed with the XU modifier. Code 87798 is included in code 87801. The 
documentation does not support that the procedure or service was distinct or independent from other services 
performed; therefore, the use of the XU modifier is not supported. Code 87641 was billed with modifier XU. 
Code 87641 is included in codes 87150 and 87801. The documentation does not support that the procedure or 
service was distinct or independent from other services performed; therefore, the use of the XU modifier is not 
supported. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 87150, 87798, and 
87461 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 
87798, and 87461 for date of service September 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513).  

You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no trial of a back brace. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shingles vaccine and its administration provided on June 16, 
2022. 
 
You asked the Plan to pay for shingles vaccine and its administration. You say that you are requesting the Plan 
to reconsider the denied claim payment. The Plan denied your request. The Plan says the vaccine and its 
administration are covered under your Part D (pharmacy) benefits, not your medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide shingles vaccine and 
its administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to shingles vaccine 
and its administration. Therefore, we decided that the Plan does not have to pay for shingles vaccine and its 
administration provided on June 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is a medical necessity for you. The Plan denied 
your request. The Plan says rules for coverage for Prolia have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve treatment with Prolia (J0897).  
 
  Benefits for Prolia 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (64635, 64636, J3301) provided on March 
16, 2023. 
 
You asked the Plan to pay for the surgical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed service. 
 
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 find that CPT codes 64635, 64636, & J3301 are not supported in the medical record. Specifically, the 
procedure report is not signed by the provider. Based on this information, we decided that Medicare rules for 
coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay 
for surgical services (64635, 64636, J3301) provided on March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87541 and 87798) provided on 
November 4, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
laboratory services (87541 and 87798) provided on November 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on 
December 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have billed the services 
at issue correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
  The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to ESRD provided on December 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart implantable pulse generator. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not been stabilized on medical therapy with repeat assessment of 
ejection fraction. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that while clinical studies led to Food and Drug Administration (FDA) approval in 2019, cardiac 
contractility modulation (CCM) remains the subject of multiple studies examining long-term efficacy, as well 
as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, this is not 
medically 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Optimizer Smart implantable pulse generator.
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 Medicare criteria and will benefit 
from acute inpatient rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your 
request. The Plan says the IRF services requested 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 do 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q0092 rendered on February 17, 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 records do not support the services billed, as the records do not indicate that portable x-ray 
equipment setup occurred. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code 
Q0092 is "Set-up portable x-ray equipment." 
 
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 there were several radiographic 
studies done on February 17, 2023. However, none of them were a chest x-ray. Thus, the setup code Q0092 is 
not supported. 
 
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 Q0092 rendered on February 17, 2023.