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

 
We decided that the Plan does not have to pay for lab services billed with codes 81003 and 87186 for date of 
service May 15, 2023. 
 
You asked the Plan to pay for codes 81003 and 87186. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says code 81003 and 87186 are not supported by the 
medical record. For code 81003, the records indicate that microscopy was performed. As a result, code 81001 
should have been billed instead. For code 87186, the records do not include lab results for this testing. 
 
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 81003 is Urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of these constituents; automated, without microscopy.  The definition of code 87186 is Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration [MIC] or 
breakpoint), each multi-antimicrobial, per plate. 
 
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 codes 81003 and 87186. Our reviewer says that codes 81003 
and 87186 are not supported by the medical record. Our reviewer found that for code 81003, the results show 
that microscopy was performed. There is a more specific code to report this test. For code 87186, there are no 
results for this lab test, it cannot be verified that the test was performed as billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 81003 and 87186 have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services billed with codes 81003 and 87186 for date of service May 15, 2023.
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 lower level of care cannot meet the 
enrollee's needs. The Plan denied your request. The Plan says the requested LTACH services are 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 is receiving appropriate care in the current setting being provided by 
the Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need help with basic care needs. The Plan 
denied your request. The Plan says the SNF services are not medically necessary.  
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 that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not require daily skilled nursing and/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 pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lightweight Expedition Aluminum Transport 
Wheelchair from an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the transport wheelchair from an OON provider. You say that it is medically 
necessary that the enrollee receives the requested ultra-lightweight, brand-specific wheelchair. The Plan denied 
your request. The Plan says the enrollee does not have coverage for an OON provider or vendor. The Plan says 
that there are benefits available for similar equipment with a participating durable medical equipment (DME) 
vendor. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 transport wheelchair from an OON 
provider. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found 
there is no documentation that the enrollee's medical needs would not be met through referral to a network 
DME provider. There is no documentation that there is anything unique about the enrollee's condition that that 
would make it medically necessary to see the requested OON provider. The documentation provided by the 
appellant is inadequate in demonstrating that a network provider would be unable to meet the Standards of Care 
required for treating the enrollees condition. 
 
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 transport wheelchair from an OON provider have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Lightweight Expedition Aluminum Transport 
Wheelchair from 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 October 27, 2022, to 
November 1, 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 G92.9 is 
supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says G92.9 is not supported in the documentation. 
 
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 G92.9, defined as 
unspecified toxic encephalopathy. 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 secondary diagnosis G92.9 is not 
supported in the documentation. Our physician reviewer found the enrollee presented with confusion in the 
setting of acute alcohol withdrawal. This condition explains the encephalopathy symptoms and without 
evidence of a separate toxin causing brain dysfunction, unspecified toxic encephalopathy 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 October 27, 2022, to November 1, 2022, 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 practitioner services provided on June 15, 2023, billed with 
codes 33228, 99152, and 99153. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says code 99152 is not payable in a facility setting, 
codes 33228 and 99152 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of codes 33228 and 99152 is moderate sedation services provided 
by the same physician or other qualified health care professional performing the diagnostic or therapeutic 
service that the sedation supports, requiring the presence of an independent trained observer to assist in the 
monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice 
time, patient age 5 years or older, and removal of permanent pacemaker pulse generator with replacement of 
pacemaker pulse generator; dual lead system. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the documentation submitted does 
not contain a procedure report stating a pacemaker generator was removed and replaced with moderate 
sedation. It cannot be verified that these procedures were performed. 
 
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 practitioner services provided have not been met. In addition, code 99153 is 
not payable in the facility setting. Therefore, we decided that the Plan does not have to pay for practitioner 
services provided on June 15, 2023, billed with codes 33228, 99152, and 99153.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlisted procedure, dentoalveolar structures (41899), 
bone graft (21210), excision of torus mandibularis (21031), and endosteal implant (21249). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested services are not covered. 
 
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 
unlisted procedure, dentoalveolar structures (41899), bone graft (21210), excision of torus mandibularis 
(21031), and endosteal implant (21249).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intravascular ultrasound (noncoronary vessel) during 
diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; 
initial noncoronary vessel (37252). 
 
You asked the Plan to pre-approve an intravascular ultrasound. You say that you disagree with the denial. The 
Plan denied your request. The Plan says a procedure similar to the one requested has already been approved for 
the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an intravascular ultrasound. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found on September 19, 2023, the enrollee apparently underwent right external 
iliac artery, right superficial femoral artery (SFA), and right anterior tibial artery intervention. The materials 
provided in support of the additional procedures predate the September 19, 2023, angiogram, and intervention. 
The medical records provided do not include an evaluation post procedure. It is unclear if there was a return of 
pulse, change or improvement in the ankle brachial index (ABI), or persistence of symptoms. There is no 
documentation in the medical records provided that additional treatment is being considered. Furthermore, the 
code in question is an add-on code that would require an initial code associated with it as the add-on code 
cannot be billed or covered as stand-alone. Recommend resubmitting with a post procedure evaluation 
demonstrating the need and rationale for additional treatments recognizing that the code in question cannot be 
billed as stand-alone in any event. 
 
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 intravascular ultrasound have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an intravascular ultrasound (noncoronary vessel) during diagnostic 
evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial 
noncoronary vessel (37252).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95861, 95937, 95938 and G0453) 
provided on May 4, 2023. 
 
You asked the Plan to pay for neuromonitoring services. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says these services were billed with an 
incorrect place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that for services provided to a patient who is registered inpatient or outpatient of a hospital, the correct POS code, regardless of where the face-to-face service occurs, is that of the appropriate inpatient POS 
code or that of the appropriate outpatient hospital POS code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of neuromonitoring services have not been met. Specifically, this claim was submitted with POS code 
22 (On Campus-Outpatient Hospital). However, the medical records indicate that the enrollee was inpatient 
status on the date in question. Therefore, the appropriate POS code for this claim would be an inpatient hospital 
code. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95861, 95937, 
95938 and G0453) provided on May 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on March 1, 2023, billed with 19 units of code 87798.

You asked the Plan to pay for the lab testing as billed. You say that this was medically necessary. The Plan denied your request. The Plan says without a lab report, the billed services cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the lab testing as billed have been met. The documentation submitted did not include a lab report. As such, it cannot be confirmed that 19 units of 87798 were performed or correctly coded. Therefore, we decided that the Plan does not have to pay for the lab testing provided on March 1, 2023, billed with 19 units of code 87798.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve duplex scan of extremity veins (93971). 
 
You asked the Plan to pre-approve duplex scan of extremity veins. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve duplex scan of extremity veins. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the services are appropriate for her symptoms and physical findings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of duplex scan of extremity veins have been met. Therefore, we decided that the 
Plan has to pre-approve duplex scan of extremity veins (93971).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an SIJ RFA. 
 
You asked the Plan to pre-approve an SIJ RFA. You say that the enrollee's condition and quality of life has 
improved with the requested procedure. The Plan denied your request. The Plan says the requested procedure 
does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an SIJ RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested procedure is considered experimental for back pain and does not meet the LCD 
criteria necessary for approval. 
 
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 SIJ RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an SIJ RFA.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the alveoloplasty (41874), the dentoalveolar structures 
(41899), and the anesthesia (00170). 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the alveoloplasty, the dentoalveolar structures, and the anesthesia are not covered by the Plan. 
 
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. 
 
The requested alveoloplasty, the dentoalveolar structures, and the anesthesia in dispute meets the Medicare 
definition of dental, since it is a service which involved the care and treatment of teeth or structures directly 
supporting the teeth. The alveoloplasty, the dentoalveolar structures, and the anesthesia do not fall under any of 
Medicare exceptions for coverage of non-routine dental care. 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 the alveoloplasty (41874), the dentoalveolar 
structures (41899), and the anesthesia (00170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory infusion pump (E0781) and supplies (A4223, 
A4221) provided on April 27, 2023. 
 
You asked the Plan to pay for the ambulatory infusion pump and supplies. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an external infusion pump may be covered if an 
infusion pump is necessary to safely administer the drug. 
 
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 ambulatory infusion pump and supplies. 
Our reviewer says that the items are not medically necessary. Our physician reviewer found documentation 
does not explain why the medication cannot be administered without an infusion pump. 
 
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 ambulatory infusion pump and supplies have not been met. Therefore, we 
decided that the Plan does not have to pay for the ambulatory infusion pump (E0781) and supplies (A4223, 
A4221) provided on April 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J3490) provided on July 3, 2023. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says the service at issue was 
not billed with the required modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 27096 
provided on July 3, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the drugs (J3490) provided on July 
3, 2023.