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

 
We decided that the Plan does not have to pay for medical services provided on November 01, 2022, billed 
with procedure codes 74230, 72040, 70100, 99204. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this service was performed by a mobile unit. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code assigned by the 
physician/practitioner for the professional component (PC) of a diagnostic service shall be the setting in which 
the enrollee received the technical component (TC) service. 
 
If the mobile unit is serving an entity for which another place of service (POS) code already exists, providers 
should use the place of service (POS) code for that entity. Place of service 11 (office) was billed, however, 
documentation received does not support the services performed in an office or other outpatient setting but 
rather in a mobile setting at a skilled nursing facility (SNF).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on November 01, 2022, billed with procedure codes 74230, 72040, 70100, 
99204.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic CGM and supplies 
 
You asked the Plan to pre-approve therapeutic CGM and supplies. You say that you believe you meet the 
requirements for a CGM. The Plan denied your request. The Plan says the enrollee does not require insulin 
three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
therapeutic CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve therapeutic CGM and supplies
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the member does not need this item. Our physician reviewer found the documentation 
doesnt support that the member has a condition that requires frequent positioning of the bed and mattress to 
alleviate pain, promote good body alignment, prevent contractures or avoid respiratory infections in a way that 
an ordinary bed is not able to. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the semi-electric hospital bed (E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee-ankle-foot orthosis (KAFO) (L2036). 
 
You asked the Plan to pre-approve the KAFO. You say that you need this item. The Plan denied your request. 
The Plan says your records do not show that your orthosis has irreparable damage or that your orthosis is at 
least 5 years old. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment, which in no case can be less than 5 years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the KAFO have not been met. Specifically, you were evaluated for this item while your current 
item was away for repairs and there is not documentation indicating the cost of the repairs were more than the 
cost of the replacement or that it could not be repaired. Therefore, we decided that the Plan does not have to 
pre-approve the knee-ankle-foot orthosis (KAFO) (L2036).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reverse total shoulder arthroplasty. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not failed conservative treatment for three months. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for primary osteoarthritis of the bilateral shoulders. There was 
no exam documented to have been performed. Detailed documentation is not evident regarding a trial and 
failure of recent, reasonable, comprehensive less invasive conservative care measures. The documentation does 
not support any physical therapy having been trialed and failed. Additionally, the magnetic resonance imaging 
(MRI) does not corroborate a massive, irreparable rotator cuff tear. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested reverse total shoulder replacement with biceps tenodesis, in this case, is not indicated to treat the 
enrollees condition and is not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a reverse total shoulder arthroplasty.
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 June 
3, 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 documents don't support this level of care. 
 
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 the history of present illness is 
problem focused.  Neither the history of present illness, past medical history nor review of systems addresses 
all of the diagnoses noted in the assessment. As such, the history is not comprehensive, and the billing of CPT 
99223 is not supported. 
 
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 June 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6751 x 3) and pontic (D6241 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee is requesting an appeal of the 
denial. The enrollee states she is unable to wear a partial denture. The Plan denied your request. The Plan says 
the criteria for coverage have not been met. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that documentation provided does not meet the criteria for coverage. Our physician reviewer found that the 
documentation indicates that multiple posterior maxillary teeth are missing. According to the criteria for 
coverage for fixed bridges, coverage may be considered for replacement of a single maxillary anterior tooth if 
there are no missing posterior teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a retainer crown (D6751 x 3) and pontic (D6241 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99220 and 99226 billed for SEptember 8, 
2022, to September 9, 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 procedure codes 99220 and 99226 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 code 99220 is initial observation 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 to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit.  
The definition of code 99226 is subsequent observation care, per day, for the evaluation and management of a 
patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed 
examination; 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 patient is unstable or has developed a 
significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the 
patient's hospital floor or unit. 
 
We find that CPT codes 99220 and 99226 are not supported in the medical record. Specifically, there is no 
documentation of a designation of observation status to support these codes. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 99220 and 99226 billed for SEptember 8, 2022, to September 9, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
need an intensive team for your care based on your current level of function, services needed can be provided 
safely in other settings, a skilled nursing facility, home with home health services or home with outpatient 
therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollees nursing medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (procedure code 99222) rendered on July 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 that the documents do not support this level of care. 
 
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 99222 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 moderate 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 moderate severity. Typically, 50 
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 supported by the medical records. Our reviewer found that the documentation in question 
supports the billing of CPT 99222. The history is comprehensive. The physical examination, while specialized 
to neurology and function, is comprehensive. The medical decision making was at least of moderate 
complexity. 
 
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 
initial hospital care (procedure code 99222) rendered on July 29, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary. 
 The Plan denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs 
can be met at a lower level of care such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted to an acute hospital with lung cancer. At the current functional level, the enrollee will not make significant functional gains in the predicted seven to ten days in an 
IRF. The document does not support necessity for admission to an IRF. The lack of complexity of the enrollee's 
nursing and medical needs does not require an acute hospital inpatient rehab stay with an interdisciplinary 
approach to rehabilitative care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a television streaming magnifier/amplifier received on April 
29, 2022. 
 
You asked the Plan to pay for a television streaming magnifier/amplifier.. You say that you were advised that 
this would be covered. The Plan denied your request. The Plan says this item is not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan does cover 
hearing aids, however it excludes coverage for personal sound boosters such as a television streaming aid.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a television streaming magnifier/amplifier. have not been met. Therefore, we decided that the Plan 
does not have to pay for a television streaming magnifier/amplifier received on April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the womens health and womens sexually transmitted 
infection (STI) polymerase chain reaction (PCR) Panel (87491, 87511, 87529, 87591, 87625, 87640, 87653, 
87481, 87661, 87798) provided on October 10, 2022. 
 
You asked the Plan to pay for the STI PCR panel. You say that the treating physician determined this testing to 
be medically necessary. The Plan denied your request. The Plan says this testing should be billed with a single 
panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a 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 STI PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the womens health and womens 
sexually transmitted infection (STI) polymerase chain reaction (PCR) Panel (87491, 87511, 87529, 87591, 
87625, 87640, 87653, 87481, 87661, 87798) provided on October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Human Papillomavirus (HPV) testing (87624) provided 
on September 9, 2022. 
 
You asked the Plan to pay for the HPV testing. You say that this testing should be covered. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for this testing. 
 
The Plan follows Medicare rules. The rules explicitly say that HPV testing is covered once every five years as 
an additional preventive service benefit under the Medicare program for asymptomatic beneficiaries aged 30 to 
65 years in conjunction with the Pap smear test. 
 
The test at issue in this appeal, the HPV testing, was requested solely for screening purposes. The enrollee is 
over the age of 65 and therefore does not meet the criteria for coverage of this service. Therefore, we decided 
that the Plan does not have to pay for the Human Papillomavirus (HPV) testing (87624) provided on September 
9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision supply, accessory (code V2797) provided on 
November 11, 2022. 
 
You asked the Plan to pay for vision supply, accessory. The Plan denied your request. The Plan says the vision 
supply, accessory is not a covered vision benefit. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
 We looked at the file and the Plan's rules. The file shows that the Plans vision benefit does not provide 
coverage for vision supply, accessory. Therefore, we decided that the Plan does not have to pay for vision 
supply, accessory (code V2797) provided on November 11, 2022.