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

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor.   
You asked the Plan to pre-approve a Dexcom G6 sensor. 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 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 use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G6 sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Dexcom G6 sensor.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on April 14, 2022. 
 
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 the records do not support the billed HIPPS code. 
 
The Plan must follow Medicare rules. Medicare rules say that a case-mix adjusted payment for a 60-day 
episode is made using one of 153 home health resource groups (HHRGs) based on HIPPS codes.  
 
We looked at the file and Medicare rules. The file shows that the records do not support the billed HIPPS code. 
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 pay for the home health services rendered on April 14, 
2022.
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 is stable to discharge to a 
LTACH level of care, however, is not clinically appropriate for a lower level of care as evidenced by the 
current chronically ill status requiring daily physician assessment and health management. The Plan denied 
your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently unstable 
for transfer to an LTACH. 
 
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 is receiving appropriate care in current acute care setting as provided by the Plan. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 29, 2023, billed with 
codes 81201-90, 81292-90, 81295-90, 81298-90, 81307-90, 81317-90, 81321-90, 81351-90 and 81334-90. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 29, 2023, billed with codes 81201-90, 81292-90, 81295-90, 81298-90, 81307-90, 81317-90, 81321-90, 
81351-90 and 81334-90.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4221 and A4222 billed for date of service 
May 18, 2023, to May 24, 2023. 
 
You asked the Plan to pay for procedure codes A4221 and A4222. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the billed codes are invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure codes A4221 and A4222 have a Status Indicator of X on the Physician Fee Schedule. 
This means that procedure codes A4221 and A4222 are statutorily excluded. Based on this information, we 
decided that Medicare rules for coverage of procedure codes A4221 and A4222 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes A4221 and A4222 billed for date of service 
May 18, 2023, to May 24, 2023.
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 you cannot be safely discharged home. You need 
IRF services to learn how to properly function after your amputation. The Plan denied your request. The Plan 
says the request is not medically necessary.  
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99203-25 performed on July 10, 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 Current Procedural Terminology (CPT) code 99203-25 (1 Unit ) remains 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 99203 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 30-44 minutes of 
total time is spent on the date of the encounter." 
 
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 do not support the use 
of CPT 99203 as separate from the procedure performed. The enrollee was seen strictly for the injection, with 
no additional evaluation of any other problems. 
 
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 99203-25 performed on July 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hyperthermic intraperitoneal chemotherapy 
(HIPEC) and cytoreductive surgery. 
 
You asked the Plan to pre-approve HIPEC and cytoreductive surgery. You say that you feel the enrollee would 
benefit from this treatment. You also say that the enrollee's condition should be treated aggressively. The Plan 
denied your request. The Plan says this is not covered when used alone or in connection with chemotherapy. 
 
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 HIPEC and cytoreductive surgery. Our 
reviewer says that the requested HIPEC and cytoreductive surgery are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided records do not support the use of HIPEC in 
this case as the guidelines indicate it is not covered when used alone or in connection with chemotherapy. 
Therefore, the reviewer found that the requested surgical services are not medically reasonable or 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 HIPEC and cytoreductive surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient hyperthermic intraperitoneal chemotherapy (HIPEC) and 
cytoreductive surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral lumbar spine medial branch block (MBB).   
 
You asked the Plan to pre-approve a medial branch block. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that this service is considered not medically necessary and is not covered. 
 The Plan follows Medicare rules. Medicare rules say that medial branch blocks may be covered under certain 
circumstances. 
 
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 medial branch block. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found that there is no physical exam 
showing the facet joint region as the pain generator. The cause of pain remains unclear and is not localized to 
the facet region. 
 
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 medial branch block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bilateral lumbar spine medial branch block (MBB).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the lumbar spine (72131) 
provided on July 7, 2023. 
 
You asked the Plan to pay for the CT scan. You say that CPT code 72131 was billed correctly and should be 
paid. The Plan denied your request. The Plan says that CPT codes 72131 and 72128 cannot be billed separately 
because they are both packaged into payment for CPT code 72128.  
 
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 code 72131 is not supported in the medical record. Specifically, codes 72131 and 72128 have 
a status indicator of Q3 in the Outpatient Prospective Payment System (OPPS). Q3 codes are packaged; its a 
composite payment for all the Q3 services. In this case, code 72128 that was billed and paid on the same date 
of service is a Q3 code. Therefore, codes 72131 and 72128 are not separately paid. Based on this information, 
we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography (CT), lumbar spine; without contrast material (72131) 
provided on July 7, 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 these services are the only safest option 
for the enrollee. The Plan denied your request. The Plan says the enrollee can receive this care in their current 
setting. 
 
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 there is no evidence that the enrollee requires services that are not currently available. 
The enrollee can remain at the current LTACH until such time no acute services are required. The enrollee can 
then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for open wound debridement, including topical application(s), 
wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session (97597) 
provided on June 27, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the wound care services. You say that you believe this claim was denied in error. 
Please review and reconsider payment. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered.  
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for open wound debridement, including topical 
application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per 
session (97597) provided on June 27, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 95861 rendered on March 16, 
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 95861 is "Needle electromyography (EMG); 2 
extremities with or without related paraspinal areas." 
 
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 do not support that the 
additional units were rendered in this case. EMG was only recorded in two limbs during this procedure.  In 
such a context it would only be appropriate to bill for one unit of the CPT code under review, which reflects 
performance of EMG in two limbs. An additional unit of service is not supported by the records. 
 
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 two units of procedure code 95861 rendered on March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 20, 2023, billed with 
codes 81216, 81241, 81279, 81298, 81307, 81311, 81317, 81321, 81334 and 81339. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing is necessary and is supported 
in the medical record. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 20, 2023, billed with codes 81216, 81241, 81279, 81298, 81307, 81311, 81317, 81321, 81334 and 81339.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 3, 2023, to 
January 5, 2023, 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 that 
secondary diagnosis code N17.0 (Acute kidney failure with tubular necrosis) was accurately reported and billed 
with the appropriate DRG. The Plan denied your request. The Plan says that the medical records did not have 
sufficient documentation to clinically validate secondary diagnosis code N17.0 (Acute kidney failure with 
tubular necrosis). Therefore, code N17.0 is not supported. 
 
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 N17.0 (Acute kidney failure with tubular necrosis). 
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 physician reviewer found that there was no elevated creatinine after hydration 
documented in the records per Kidney Disease Improving Global Outcomes (KDIGO) guidelines. The medical 
records do not support the billing code. 
 
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 January 3, 2023, to January 5, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93355 billed for date of service February 15, 
2023.  
 
You asked the Plan to pay for procedure code 93355. You say that 93355 should be paid as billed because it is 
supported in the documentation. The Plan denied your request. The Plan says payment for code 93355 is 
bundled into payment for code 00567. 
 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 93355 
is a column two code to column one code 00567 with a modifier indicator of 0. The column two 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 93355 billed for date of service February 15, 
2023.