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 November 4, 2022, to 
November 15, 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 
medical records support the billing of J15.6 (gram negative pneumonia), so the claim should be paid at the 
DRG originally billed. The Plan denied your request. The Plan says the billed diagnosis of J15.6 (gram 
negative pneumonia) is not supported by the medical record. As a result, a lower DRG was paid. 
 
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 a diagnosis of J15.6 (gram negative pneumonia). 
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 the diagnosis of J15.6 (gram negative pneumonia) is not supported by 
the medical record. Our physician reviewer found the patient was a 71-year-old woman with history of chronic 
obstructive pulmonary disease who presented with shortness of breath and hypoxia. The patient had a dry 
cough and chest imaging showed multifocal bilateral infiltrates. The documentation supports a pneumonia, but 
there is no clear evidence of a gram-negative organism,  
 
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 4, 2022, to November 15, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the breast. 
 
You asked the Plan to pre-approve the MRI. You say that due to the dense tissue further diagnostic testing is 
medically necessary. The Plan denied your request. The Plan says that there is no documentation in the clinical 
records and radiology reports received suggesting the need for additional testing. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found you have extremely dense tissue on your 
mammography. There is no increased genetic risk for MRI. However, the plan has stated there is no data 
supporting the use of MRI in this scenario which is incorrect. The literature has abundant evidence that 
mammography in cases of extremely dense tissue is very limited and further testing either whole breast 
ultrasound or MRI is advised. In this case the use of an MRI as an adjunctive testing is reasonable due to the 
marked limitations of mammography in patients with extremely dense tissue.  
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance imaging (MRI) of the breast.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 20, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing is covered by Medicare. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
device. 
 
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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin or have low blood glucose levels. 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 
a Freestyle Libre 2 continuous glucose monitor (CGM) device.
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 
May 9, 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 May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on June 21, 2023. 
 
You asked the Plan to pay for the podiatry services. You say that the enrollee was in a nursing home and could 
not choose a network provider. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the podiatry services 
provided on June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV), group 1 heavy-duty, 
patient weight capacity 301 to 450 pounds (K0801). 
 
You asked the Plan to pre-approve a POV. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says you do not meet criteria for approval of the 
requested device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 The file does not show which mobility deficits you have that impairs your participation in MRADLs. There is 
no documentation that your condition can be improved by a walker, cane or manual wheelchair and there is no 
home assessment, demonstrating that there is enough room in your home for the requested device. This means 
that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (POV), group 1 heavy-duty, patient weight capacity 301 to 450 
pounds (K0801).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no documentation in the submitted 
records of attempts to try conservative measures including 6 weeks of physical therapy (PT). Absent a red flag, 
the medical necessity of the requested MRI cervical spine has not been established without a 6-week trial of 
PT. 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing-four or more teeth 
per quadrant (D4341) provided on June 15, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under the 
supplemental dental policy.  
 
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. 
 
 
  
 
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal 
scaling and root planing-four or more teeth per quadrant (D4341) provided on June 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the inpatient transforaminal lumbar 
laminectomy/decompression and instrumental fusion at L4-L5. 
 
You asked the Plan to pre-approve  the inpatient transforaminal lumbar laminectomy/decompression and 
instrumental fusion at L4-L5 . You say that the enrollee has severe lumbar stenosis and will unlikely improve 
with conservative management of symptoms. The Plan denied your request. The Plan says the inpatient transforaminal lumbar laminectomy/decompression and instrumental fusion at L4-L5 is not medically 
necessary. The Plan says smoking is a contradiction to spinal fusion surgery.  
 
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 inpatient transforaminal lumbar 
laminectomy/decompression and instrumental fusion at L4-L5. Our reviewer says that the requested service is 
not considered medically reasonable and necessary in this case. Our physician reviewer found there is no 
documentation of smoking cessation. Smoking is a contraindication to fusion. The records show that the 
requested inpatient admission is related to a non-covered service. 
 
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 inpatient transforaminal lumbar laminectomy/decompression and 
instrumental fusion at L4-L5 have not been met. Therefore, we decided that the Plan does not have to pre-
approve  the inpatient transforaminal lumbar laminectomy/decompression and instrumental fusion at L4-L5.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed with the XI 
modifier for date of service February 16, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87653 and 87798. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these codes are 
not supported for separate payment, but it has paid for code 87801. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -XU modifier if 
the service billed with the modifier indicates an Unusual Non-Overlapping Service.  
 
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 procedure codes 87481, 87653 and 87798. Our reviewer says that the use of the XU modifier for procedure codes 87481, 87653 and 87798 is not 
supported in the medical record. Our physician reviewer found although you reported the XU modifier for 
these codes, the laboratory report does not include documentation to support an unusual non-overlapping 
service from code 87801. 
 
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 codes 87481, 87653 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed with the XI 
modifier for date of service February 16, 2023.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for code 23600. We decided that the Plan does not have to pay for code 
99285.  
 
You asked the Plan to pay for codes 23600 and 99285 billed for date of service April 4, 2023. You say that 
these services were necessary and are supported as billed.  The Plan says that these codes are not supported by 
the medical record.  
We decided that the Plan has to pay for code 23600.  In this case, the CPT Code Manual definition of code 
23600 is Closed treatment of proximal humeral (surgical or anatomical neck) fracture.  We sent this case to a 
physician reviewer to determine if this code was supported.  The doctor says that this code is supported by the 
medical record.  The doctor found that documentation shows an x-ray with proximal humeral fracture, so CPT 
23600 is supported.  Therefore, we decided that the Plan has to pay for code 23600 .  
 
We also decided that the Plan does not have to pay for code 99285. 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.  Our physician reviewer found that this code is not supported by the medical 
record.  The doctor says that while the documentation supports a comprehensive exam, it does not support a 
comprehensive history or medical decision making of high complexity. 
 
 Therefore, we decided that the Plan does not have to pay for code 99285. 
 
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: 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 the enrollee has multiple complex 
medical issues that cannot be managed at a lower level of care and will need ongoing daily physician 
management.  The Plan denied your request. The Plan says the LTACH services are not medically necessary, 
and the enrollee's needs can be met at a lower level of care. 
 
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 was admitted with altered mental status in the setting of sepsis and 
gastrointestinal bleeding. The record indicates that the enrollee has ongoing acute medical issues and still requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one 
way and air mileage provided on November 8, 2021.  
You asked the Plan to pay for the air ambulance services and air mileage. You say that the medical records 
support the medical necessity for the air ambulance services. The Plan denied your request. The Plan says after 
reassessing the entire clinical situation, information provided at the time of the appeal does not support criteria 
for air ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services and air mileage. 
Our reviewer says that the air ambulance services were not medically necessary. Our physician reviewer found 
given that the sending facility had already provided intensive care unit care, two bypass surgeries and 
interventional neurology, it appears that the sending facility was capable of caring for the enrollee. There is no 
documentation of specific services that were required by, and not available to, the enrollee. As such, the 
documentation does not show that the transfer was 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 air ambulance services and air mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one way 
and air mileage provided on November 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve (the Intracept procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the service should be approved so the 
enrollee can receive the relief from vertebrogenic pain they deserves. The appellant says the enrollee has failed 
non-operative treatment and the Intracept procedure is the only solution to treat the source of her chronic low 
back pain.  The Plan denied your request. The Plan says the Intracept procedure is not medically necessary. The 
Plan says the basivertebral nerve (BVN) is not the primary cause of pain.  
 
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 Intracept procedure. Our reviewer 
says that the requested service is 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 
degenerative joint disease or stenosis. This means the cause of 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the thermal destruction of intraosseous basivertebral nerve (the Intracept 
procedure).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cologuard test (81528). 
 
You asked the Plan to pre-approve a Cologuard test. You say that this is medically necessary. The Plan denied 
your request. The Plan says records show that you had the Cologuard test done on April 26, 2021, which is less 
than 3 years ago. 
 The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered once every three 
years when specific criteria are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Cologuard test have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Cologuard test (81528).