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

 
We decided that the Plan does not have to pay for an additional unit of procedure code 71275 rendered on 
January 7, 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 coding and billing requirements have not been met.  
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 [Enter billing code at issue (e.g. 43856, K0002, etc.)] is 
"Computed tomographic angiography (CTA), chest (noncoronary), with contrast material(s), including 
noncontrast images, if performed, and image postprocessing." 
 
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 only a single CTA of the chest 
was done on this date of service. There are duplicate reports of the same study in the submitted 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 an additional unit of procedure code 71275 rendered on January 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 December 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
December 9, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that these services were provided in 
good faith and should be paid. 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 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service December 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each dialysis treatment provided on 
January 08, 2022, to June 29, 2022. 
 
You asked the Plan to waive the coinsurance for each dialysis treatment. You say that you cannot afford these 
coinsurance amounts. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for each dialysis treatment. This item/service falls within the 
services to treat kidney disease benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
each dialysis treatment provided on January 08, 2022, to June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service January 5, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the progress notes support the level of care. The 
Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. Specifically, the documentation does not record the total time that critical care services 
were furnished. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed 
for date of service January 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code A41.51 
rendered from July 12, 2021, to July 20, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated. 
 
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 DRG 871. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee's findings did not sufficiently meet the Sepsis 3 criteria. There was insufficient evidence of a 
systemic infection causing a dysregulated response leading to life-threatening organ failure. Therefore, the 
code, A41.51 (sepsis due to E. Coli) is not supported. Therefore, DRG 444 is more appropriate for this 
admission based on the provided documentation.  
 
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 billed with diagnosis code A41.51 rendered from July 12, 2021, to July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable loop recorder (ILR) (33285). 
 You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not 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 service. Our physician reviewer 
found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or 
any other apparent indication for an implantable cardiac monitor (ICM). In summary, there is insufficient 
documentation to support the medical necessity for insertion of an ICM in this enrollee's clinical management. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the implantable loop recorder (ILR) (33285).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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) to be provided at an out-of-network 
provider for a lower in-network cost. 
 
You asked the Plan to pre-approve the service. You say that you need this high-risk surgery. You state that you 
only have one good eye, and you went to a doctor that were in-network, but this provider would not do surgery 
because you are high risk. You state that you found a doctor who would do surgery. The Plan denied your 
request. The Plan says you are a high-risk patient, and you need to see this provider because this provider can provide transportation for the surgery and the follow up visit. The Plan states according to their research, there 
are multiple providers within 15 miles of you that are accepting new patients within one to two months and 
able to perform cataract surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
Your records received do not indicate that you have an emergent or urgent medical condition or are in need of 
specialized service(s) that are not available in the network. You have a Preferred Provider Organization (PPO) 
plan. The Plan has in-network providers (doctors and facilities) within a reasonable distance from your location 
that can provide this service or item at a lower cost. If you want to pay a lower cost, then you must receive your 
care from an in-network provider. You can find a list of in-network providers in your Provider Directory. You 
may discuss this with your provider. Based on this information, we decided that Medicare rules for coverage of 
the service have not been met. Therefore, we decided that the Plan does not have to pre-approve 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) to be provided at an out-of-network provider for a lower in-network cost.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services billed with code J3490 for March 1, 2023. 
 
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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intraoperative services are included in the global 
surgical package.  
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same day as minor surgical procedure 64420. Payment for code J3490 is included in the global surgical payment for code 
64420. Therefore, we decided that the Plan does not have to pay for the drug services billed with code J3490 
for March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 7, 2022, billed 
with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81334 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically 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 
November 7, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81334 and 
81351.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4557 billed for date of service January 26, 
2023. 
 
You asked the Plan to pay for procedure code A4557. You say that the records support medical necessity. The 
Plan denied your request. The Plan says procedure code A4557 is considered bundled and not separately 
payable.  
 
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 A4557 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4557 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
A4557 billed for date of service January 26, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for hospital services provided on February 16, 2023. 
 
You asked the Plan to pay for the hospital services. You say that you fell and your husband called 911 as you 
believed you had broken a bone. You says the ambulance took you to the nearest hospital for care. The Plan 
denied your request. The Plan says that the services are not covered under Medicare. 
 
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. Specifically, the Plan has not provided a Medicare rule or a Plan rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for hospital services provided on 
February 16, 2023.  
 
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 pay for hospital discharge day management; more than 30 minutes 
rendered on September 29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that hospital discharge day 
management was reported to have been rendered on September 29, 2022. However, the provided 
documentation did not include an encounter note or other evidence of hospital discharge day management of more than 30 minutes having been performed for this patient on that date. Therefore, the records do not 
sufficiently support that CPT 99239 was rendered in this case. 
 
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 hospital discharge day management; more than 30 minutes rendered on September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481 and 87653 billed for date of 
service November 15, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481 and 87653. You say that these services were 
reported correctly. The Plan denied your request. The Plan says these services are not supported for separate 
reporting. 
 
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 code87150 
is a column II code to column I code 87500, and codes 87481 and 87653 are column II codes to column I code 
87801. Codes 87481 and 87653 were not billed with an appropriate modifier to bypass the edit. Based on the 
claim submitted, Medicare billing criteria have not been met for codes 87481 and 87653. However, code 87150 
was billed with a modifier. 
 
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 procedure code 87150. Our reviewer says that code 87150 is 
not supported for separate reporting with modifier XU. Our reviewer found the laboratory report does not 
include documentation to support culture typing was an unusual non-overlapping service from infectious agent 
detection, and therefore 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 procedure codes 87150, 87481 and 87653 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87150, 87481 and 87653 billed for date of 
service November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided on January 20, 2023. 
 
You asked the Plan to pay for durable medical equipment. The Plan denied your request. The Plan says the 
members plan excludes coverage for this out of network service. 
 
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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for durable medical equipment provided on January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional tracheostomy masks (A7525) and oral 
swabs (E1399). 
 
You asked the Plan to pre-approve 2 additional tracheostomy masks and oral swabs. You say that the additional 
masks and swabs are medically necessary. The Plan denied your request. The Plan says coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare allows 1 tracheostomy mask per 
month. 
 
We looked at the file and Medicare rules. The plan has already approved 4 tracheostomy masks per month. The 
additional masks are non-covered. The swabs are disposable items and are not covered. Based on this 
information, we decided that Medicare rules for coverage of 2 additional tracheostomy masks and oral swabs 
have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional tracheostomy 
masks (A7525) and oral swabs (E1399).
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 the enrollee meets LTACH admission 
criteria, and their ongoing medical needs warrant an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says admission to an LTACH 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 all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and overdenture 
complete mandibular (D5865). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are either not covered under your dental plan or your benefit 
for the requested item or service has been exhausted. 
 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, certain limitations apply. The record 
shows your benefit for D5110 exhausted on date of service April 28, 2023. Additionally, D5865 is not covered 
under any circumstance. Therefore, we decided that the Plan does not have to pre-approve a maxillary 
complete denture (D5110) and overdenture complete mandibular (D5865).