Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for angiography (procedure code 75774) rendered on October 21, 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 records do not support the services billed, as this is part of the primary procedure and not 
eligible for separate payment. 
 
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 75774 is "Angiography, selective, each additional vessel studied after basic examination, radiological 
supervision and interpretation (List separately in addition to code for primary procedure)." 
 
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 supports coverage 
of the procedure in question. The initial diagnostic angiography is separately billable and not a component of 
the embolization code. There is satisfactory documentation that a visceral angiogram was performed (75726). 
There is also satisfactory documentation of a repositioning of the catheter to obtain additional diagnostic 
angiographic information of a separate vessel as indicated with code +75774. As this add-on code was billed 
with an appropriate initial code (75726) at the time of billing it is an appropriate use of the add on code. 
 
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 
angiography (procedure code 75774) rendered on October 21, 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the prescription glasses provided on November 15, 2022. 
 
You asked the Plan to pay for the prescription glasses. You say that you could not use your glasses because 
they were scratched and cracked. You say you are on a limited income and your eyeglass benefits are very 
important. The Plan denied your request. The Plan says that the benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit valid documentation showing that the Plan paid for 
eyewear in 2021. Therefore, we decided that the Plan has to pay for the prescription glasses provided on 
November 15, 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 pay for a pneumatic compression device (E0675) and a segmental 
gradient pressure pneumatic appliance, half leg (E0673) provided on October 3, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and an appliance. You say that you disagree 
with the denial and have submitted medical records for review. The Plan denied your request. The Plan says a 
pneumatic compression device is not covered by Medicare when the place of service is an ambulatory surgical 
center. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  The item at issue in this appeal is for use outside of the home. The records show you billed with place of 
service 24, which is an ambulatory surgical center. Medicare rules state that for durable medical equipment to 
be covered, it must be appropriate and be needed for use inside the home. Medicare does not consider an 
ambulatory surgical center a home. Therefore, we decided that the Plan does not have to pay for a pneumatic 
compression device (E0675) and a segmental gradient pressure pneumatic appliance, half leg (E0673) provided 
on October 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the services at issue have been billed 
correctly. 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. 
 
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 procedure code 99223. Our reviewer says that the code at 
issue does not meet criteria for payment. Our reviewer found that the evaluation and management code billed 
requires a comprehensive history, a comprehensive examination and medical decision making of high 
complexity. In this case, the available records supported that there was a comprehensive exam and medical 
decision making of high complexity. However, the medical records submitted did not support 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 procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 billed for date of service February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osteogenesis stimulator, low intensity ultrasound, 
non-invasive (E0760). 
 
You asked the Plan to pre-approve the osteogenesis stimulator. You say that you had injured your little toe on 
the foot of your bed. Your doctor referred you to the podiatrist who ordered another x-ray and put you in a boot 
for your foot and on the second visit they ordered bone stimulator. The Plan denied your request. The Plan says 
there has not been a minimum of 90 days between x-rays or documentation by the doctor that there has not 
been clinical significant evidence of fracture healing. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment 
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days. 
 
In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not 
show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased. Therefore, we decided that the Plan does not have to pre-approve the osteogenesis stimulator, low 
intensity ultrasound, non-invasive (E0760).
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75710. We decided that the Plan does not have to pay for 37225 and 
37229.  
 
You asked the Plan to pay for procedure codes 37225, 37229, 75710 rendered on December 2, 2021.. You say 
that this should be paid for. The Plan says that the records do not support the services billed. 
 We decided that the Plan has to pay for 75710.  
 
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 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 for CPT 75710. Our reviewer says that this codes for 
diagnostic angiogram, supervision and interpretation of an extremity. There is satisfactory documentation that a 
lower extremity angiogram was performed and there is sufficient detail with respect to description of findings 
to justify use of this code.  
 
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 been met. Therefore, we decided that the Plan has to pay for 
75710.  
 
We also decided that the Plan does not have to pay for 37225 and 37229. 
 
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 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 for CPT 37227 and CPT 37229. Our reviewer says that 
these code for atherectomy (with or without percutaneous transluminal angioplasty) of a tibial artery and 
femoral-popliteal artery respectively. In this case, there is not sufficient documentation that meaningful 
atherectomy with angioplasty was performed on which to overturn the health plan decision. This is supported 
by the documentation that the patient is being planned to bring back to access retrograde and attempt 
again. Attempted but failed procedures are generally not billable.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37225 and 37229 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37225 and 37229. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 40-trip limit. 
 
You asked the Plan to pre-approve additional trips for routine transportation. You say that you need 
transportation to scheduled appointments. The Plan denied your request. The Plan says the requested trips 
exceed your transportation benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 40 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that the requested trips 
exceed your 40-trip limit. Based on this information, we decided that you have exhausted the Plan maximum 
benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 
additional trips for routine transportation beyond the Plan's 40-trip limit.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation to a doctor's office. The Plan denied your request. The Plan says the requested trip exceeds the 
Plan's mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage for routine transportation beyond the Plan's 50-mile limit.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation to the welfare office. 
 
You asked the Plan to pre-approve routine transportation to the welfare office. You say that you need 
transportation to discuss housing. The Plan denied your request. The Plan says the welfare office is not a 
covered location. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation to Plan-approved locations. 
 
We looked at your request, the records in the case file, and the rules. The requested transport to the welfare 
office does not meet the criteria for Plan-approved locations for routine transportation. Based on this 
information, we decided that the Plans rules for coverage of routine transportation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve routine transportation to the welfare office.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on October 06, 2022. 
 
You asked the Plan to pay for surgery. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for surgery provided on 
October 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 sensor. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a FreeStyle Libre 2 sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 14, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99231) rendered 
from May 14, 2022, to May 15, 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) code 99231 (1 Unit) 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 99231 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem 
focused interval history; A problem focused examination; Medical decision making that is straightforward or of 
low 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 stable, recovering or improving. Typically, 15 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 documentation submitted does 
not contain any progress notes for the dates of service in question. The CPT codes in question cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99231) rendered from May 14, 2022, to May 15, 
2022.
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 March 3, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this service was medically necessary. 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 March 3, 2022, billed 
with code 99153.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments (97810, 97811, 97813, 97814). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the acupuncture services were not requested on the 
basis of a covered diagnosis. Additionally, you are requesting services from an ineligible provider.  
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. The rules also say that Medicare payment cannot be made to a provider that is not enrolled in 
the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
requested on the basis of a diagnosis for chronic low back pain. Additionally, the provider in this case is not 
enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture treatments (97810, 97811, 97813, 97814).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia (codes D9222, D0223) 
provided on September 20, 2022. 
 
You asked the Plan to pay for deep sedation/general anesthesia. You say that deep sedation was needed due to 
the number of teeth that were taken out. The Plan denied your request. The Plan says deep sedation/general 
anesthesia is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for deep 
sedation/general anesthesia (codes D9222, D0223) provided on September 20, 2022.