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

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve (64628 and 64629). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure is experimental. More research is needed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the thermal destruction of intraosseous basivertebral nerve (64628 and 64629).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on October 18, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99285. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for procedure code 99285. Our reviewer says 
that the medical records do not support the billing of code 99285. Our reviewer found the documentation 
available for review does not support that the presenting problems were of high severity or that the medical 
decision was of high complexity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on July 
14, 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 Current Procedural Terminology (CPT) 99223 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 a comprehensive history requires 
a chief complaint, an extended history of present illness, a review of all additional body systems and a 
complete past, family and social history. The provided records in this case do not document a comprehensive 
history. 
 
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 initial hospital care (procedure code 99223) rendered on July 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 20, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The documentation does not support that the enrollee being symptomatic or at high risk for an unusual 
pathogen, other than the enrollees age. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on October 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 a Vertiflex Superion Interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is 
needed. 
 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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the discharge management services provided on April 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code is 
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 99238 is "Hospital discharge day management; 30 minutes or less". 
 
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 use of code 99238 is 
supported by the records provided. Our reviewer found that the note for the date of service in question contains 
the final examination, hospital course, and discharge instructions for the patient. Since no time is documented, 
it is coded as less than 30 minutes. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the discharge management services provided on April 3, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the enrollee for the total electric hospital bed (E0265) 
provided on December 20, 2021. 
 
You asked the Plan to reimburse the enrollee for the hospital bed. You say that the enrollee needed a bed in 
place before they could be discharged from the hospital. The Plan denied your request. The Plan says the 
provider in this case is not a network provider. The Plan says that the provider is not certified for Medicare. 
The Plan also says that payment cannot be made for items that were supplied by a provider that is not certified 
for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse the enrollee for the total electric 
hospital bed (E0265) provided on December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition supply kit (B4220) and the parenteral 
nutrition administration kit (B4224) provided from September 26, 2022, through September 30, 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 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. 
 
Codes B4220, B4224 are adjudicated as claim line edits and have an MUE value of 1. The provider billed 3 
units; therefore, all units are denied. 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 the parenteral 
nutrition supply kit (B4220) and the parenteral nutrition administration kit (B4224) provided from September 
26, 2022, through September 30, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the TriVisc 25MG/2.5ML injection (J7329). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says they do not have a record from your prescriber that shows you have tried one of the preferred drugs (Monovisc, Orthovisc, Synvisc or Synvisc One), or that you have medical 
reasons that prevent you from using one of them. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the case file does not contain documentation of trial and failure of Monovisc, Orthovisc, Synvisc or 
Synvisc One. The documentation does not support that Monovisc, Orthovisc, Synvisc or Synvisc One would 
likely be less effective, and/or would likely have adverse effects for you in this case. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the TriVisc 25MG/2.5ML injection (J7329).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided on April 7, 2021. 
 
You asked the Plan to pay for ambulance services. You say that you should not be responsible for these 
charges. The Plan denied your request. The Plan says that this claim was not billed correctly because the 
mileage was not reported to the nearest tenth of a mile. 
 
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. Medicare rules state that ambulance trips totaling up to 100 covered miles should be reported by 
rounding mileage to the nearest tenth of a mile. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The provider reported 46 miles for the mileage on this claim. It may be that 46.0 
miles was the nearest tenth of a mile for this trip. The Plan did not submit medical records or make reasonable 
efforts to obtain medical records related to this trip. Without records, we cannot determine what the exact 
mileage of this trip was. Therefore, the Plan has not shown that its decision to deny payment for this ambulance 
trip is correct or justified according to billing guidelines. Therefore, we decided that the Plan has to pay for 
ambulance services provided on April 7, 2021.  
 
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 pay for the additional moderate sedation time provided on date of 
service July 11, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the additional moderate sedation time provided on date of service July 11, 2022, billed with 
code 99153.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an urgent care office visit provided on September 1, 2022, by 
an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that you believed you may have an ear 
infection as a result of COVID, but that it ended up being you eustachian tube being blocked. You state that the 
care in dispute was urgent in nature. The Plan denied your request. The Plan says the enrollee received 
treatment from an out-of-network provider without a referral or an authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found the enrollee could not 
have foreseen requiring the services, however, the records do not indicate the care provided was medically 
necessary. The services could have been delayed and were not an emergency. 
 
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 out-of-network services have not been met.   
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for the out-of-network services. Therefore, we decided that the 
Plan does not have to pay for an urgent care office visit provided on September 1, 2022, by an out-of-network 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on September 1, 2022, billed 
with code 73552-26-RT. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes that are unspecific or bilateral 
are not appropriate for lines with RT or LT modifiers appended. 
 
We looked at the file and Medicare rules. In this case, you billed code 73552-26-LT with diagnosis code 
M24.60 which is used for unspecified joint and is not appropriate for lines with an LT modifier appended. 
Based on this information, we decided that Medicare rules for coverage of radiology services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for radiological services provided on 
September 1, 2022, billed with code 73552-26-RT.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post stabilization care provided on June 22, 2021, to June 24, 
2021.  
You asked the Plan to pay for post stabilization care. You say that you were told you did not need prior 
authorization. The Plan denied your request. The Plan says these services have been correctly denied. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our reviewer says 
that post stabilization case was not medically necessary. Our physician reviewer found the treating physician 
did not document that the enrollee was not stable for transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post stabilization care provided on June 22, 2021, to June 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on August 10, 2022, and August 12, 2022. Comparison of the two claims shows these are exact 
duplicates. There is no evidence presented to support that the billed services were provided twice on the same 
date. Based on this information, we decided that the Medicare rules for the services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 24, 
2022.
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's medical needs cannot be 
provided for at a lower level of care. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval. 
 
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 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.