Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transluminal dilation of aqueous outflow canal; without 
retention of device or stent (66174-55) and the extracapsular cataract removal with insertion of intraocular lens 
prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or 
phacoemulsification); without endoscopic cyclophotocoagulation (66984-55) provided on October 11, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the billed modifier is not appropriate 
 
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 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 found for code 66174-55 - 
Transluminal dilation of aqueous outflow canal; without retention of device or stent does not meet criteria for 
billing or reimbursement consideration. The medical records provided does not include sufficient 
documentation to support the use of modifier 55 appended to procedure 66174 for date of service October 11, 
2022; therefore, this procedure cannot be verified. 
 
For code 66984-55,  Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage 
procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without 
endoscopic cyclophotocoagualtion does not meet criteria for billing or reimbursement consideration. The 
medical records provided does not include sufficient documentation to support the use of modifier 55 appended 
to procedure 66984 for date of service October 11, 2022; therefore, this procedure cannot be verified 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for transluminal dilation of aqueous outflow canal; without retention of device or stent (66174-55) 
and the extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual 
or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic 
cyclophotocoagulation (66984-55) provided on October 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 26, 2021, 
through November 30, 2021, and billed with diagnosis code J96.21. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis J96.21 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of J96.21. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.21 - Acute and 
Chronic Respiratory Failure with Hypoxia. 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 documentation does not 
support secondary diagnosis code J96.21. Our physician reviewer found the member did not require high flow 
oxygen support, bilevel positive airway pressure (BiPAP), or vent support. Therefore, diagnosis code J96.21 - 
Acute and Chronic Respiratory Failure with Hypoxias is not sufficiently supported as a secondary diagnosis.   
 
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 26, 2021, through November 30, 2021, and billed with 
diagnosis code J96.21.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from July 22, 2022, to August 11, 2022. 
 You asked the Plan to pay for SNF care. You say that you need SNF level of care to regain your strength, 
mobility, functional ambulation, communication, and independence. The Plan denied your request. The Plan 
says skilled nursing facility care was no longer required. 
 
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 pay for 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 that you did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You did not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 pay for SNF care provided from July 22, 2022, to August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 9, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 pay for the pneumatic compression device provided on August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you are requesting 
reconsideration stating services are medically necessary. The Plan denied your request. The Plan says the 
request is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99402 billed for date of service December 5, 
2022. 
 
You asked the Plan to pay for procedure code 99402. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is non-covered. 
 
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 code 99402 has a Status Indicator of N on the Physician Fee Schedule. This means that procedure code 99402 is not covered. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99402 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99402 billed for date of service December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of a root canal obstruction; non-surgical 
access (D3331), an intraorifice barrier (D3911) and a therapeutic parenteral drug, single administration 
(D9610). 
 
You asked the Plan to pre-approve dental services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the requested services are not listed as a covered benefit. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
treatment of a root canal obstruction; non-surgical access (D3331), an intraorifice barrier (D3911) and a 
therapeutic parenteral drug, single administration (D9610).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 12, 2022, 
to September 17, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis A41.9, described as sepsis, 
unspecified organism. 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 documentation does not support the billed code. 
Our physician reviewer found that the enrollee presented with shortness of breath.  She was found to have 
rhinovirus and was treated for chronic obstructive pulmonary disease, and possible pneumonia. There is no 
evidence that the enrollee had hypotension, hypoperfusion or organ failure. As such, a diagnosis of sepsis and 
the billing of A41.9 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 September 12, 2022, to September 17, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is the appropriate 
level of care to manage the enrollee's ongoing critical care needs. The Plan denied your request. The Plan says 
the request is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx (0339U) provided on January 13, 2023, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the test was requested directly from the treating 
physician who makes the professional determination of diagnosis and medical necessity to successfully treat 
the enrollee. The Plan denied your request. The Plan says the request for SelectMDx is not a covered benefit 
because this is not a test which has met the coverage criteria. Enrollees must receive their medical services 
from an in-network provider. 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 SelectMDx (0339U) provided on January 13, 
2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 3, 2021, to 
April 7, 2021, 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 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis code A41.9, described as sepsis, 
unspecified organism. 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 documentation does not support the billed code. 
Our physician reviewer found the enrollee presented with chief complaint of dyspnea, fever and weakness. This 
enrollee has known history of oxygen dependency (4 Liters at home) and respiratory bronchiolitis and 
interstitial lung disease due to cigarette smoking. Pertinent vital signs initially included temperature of 104. 
Leukocytosis was documented. Lactic acid was state to be "not elevated". She was diagnosed with pneumonia 
and was treated with antibiotics and corticosteroids. In this case, there was no clinical or laboratory evidence of 
sepsis.  
 
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 April 3, 2021, to April 7, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency services provided on November 20, 2022. 
 
You asked the Plan to pay for the emergency services. You say that this claim should not have denied as a 
duplicate. The Plan denied your request. The Plan says the claim did not deny because it was a duplicate.  The 
claim denied because the patient was incarcerated at the time of the services, so the Plan states they are not 
responsible for this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for medical services 
provided to prisoners or individuals in state or local government custody.  
The medical records in this case confirm that the patient was incarcerated at the time of the services at issue. 
The medical records explicitly state "the patient is currently under arrest coming from jail."  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency services have not been met. Therefore, we decided that the Plan does not have to 
pay for emergency services provided on November 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 26, 2022, billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81240,81241, 81291, 81306, 81328, 81355, 81335, 81401, 
0031U, 0032U, 0033U, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary. 
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 
March 26, 2022, billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81240,81241, 81291, 81306, 
81328, 81355, 81335, 81401, 0031U, 0032U, 0033U, and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80503 billed for date of service October 8, 
2022. 
 You asked the Plan to pay for procedure code 80503. You say that this service was billed correctly and is 
separately payable. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 80503 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 80503 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 80503 billed for date of service October 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says custodial care is 
not covered. 
 
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 services. Our physician reviewer 
found that the enrollee has cognitive deficits. The most recent therapy documentation indicates the enrollee is 
able to ambulate household distances with a walker and contact guard assistance. The enrollee is medically 
stable and does not have any complex daily wound care, parental medications or required care for a new or 
malfunctioning feeding tube. His physical function is at or near his baseline. Therefore, an admission to the 
nursing facility at a skilled level of care for inpatient skilled services was 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services billed with code 81599 for October 22, 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 that the claim was not billed with the required Dex-Z identifier. 
 
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 states that the claim was not billed with the required Dex-Z identifier; 
however, the referenced Local Coverage Determination (LCD) L36807 and Local Coverage Article (LCA) 
A57772 are not binding for the state of Colorado where the testing was performed. There is no binding LCD or 
LCA for this state that requires a Dex-Z identifier. The Plan has not provided any binding Medicare rules or 
documentation to support that the services are not payable as billed. Therefore, we decided that the Plan has to 
pay for the laboratory services billed with code 81599 for October 22, 2022.  
 
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.