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

 
We decided that the Plan does not have to pay for surgical assistant services (22015) provided on October 19, 
2022. 
 
You asked the Plan to pay for the surgical assistant services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says this service is not eligible for payment. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 22015. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for 
surgical assistant services (22015) provided on October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator billed for date of service 
November 12, 2022. 
 
You asked the Plan to pay for the billed services. You say that E0745 is an acceptable procedure code. The 
Plan denied your request. The Plan says the device is not covered for the documented diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that neuromuscular electrical stimulation is only 
covered under certain medical indications.  
 
We looked at the file and Medicare rules. The file shows that the stimulator device was provided for the 
treatment of osteoarthritis and a lower leg fracture. The provided device is not a covered benefit for the treating 
diagnoses.  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 the neuromuscular stimulator billed for date 
of service November 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine disposable supplies (A0398) provided on 
December 26, 2022. 
 
You asked the Plan to pay for the routine disposable supplies. You say that you had to be transported to the 
emergency room from urgent care by ambulance because you were in atrial fibrillation, your heart rate was too 
high, and you could have had a stroke. You also say that you cannot afford a $1,088.00 bill. The Plan denied 
your request. The Plan says routine disposable supplies are not covered by Medicare. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for the routine disposable supplies (A0398) provided on 
December 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MOHS micrographic surgery. 
 
You asked the Plan to pre-approve the MOHS surgery. You say that the mole is cancerous, and it needs to be 
removed immediately. The Plan denied your request. The Plan says a MOHS procedure is not reasonable or 
necessary in this case. 
 
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 MOHS surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Squamous cell carcinoma in situ, (confined to its site of origin) located on the upper 
back does not require MOHS surgery. 
 
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 MOHS surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve MOHS micrographic surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service April 17, 
2022. 
 
You asked the Plan to pay for the billed services. 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 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.  
 We find that CPT code 99223 is not supported in the medical record. Specifically, the medical records do not 
support that a comprehensive history was documented on the date of service at issue.  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 99223 billed for date of service April 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve Ondansetron tablets. The Plan denied your request. The Plan says 
Ondansetron for chemotherapy induced nausea and vomiting falls under Part D, and is not covered under Part 
B. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron tablets.  
 
Benefits for Ondansetron tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on September 7, 2021, to 
September 12, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code N17.9 (unspecified acute 
kidney failure). 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 records do not support the billing of secondary 
diagnosis code N17.9. Our physician reviewer found the enrollee was admitted to the hospital with weakness 
and abdominal pain. She was diagnosed and treated for colitis and dehydration. At the time of presentation, her 
vital signs were stable and she had laboratory studies that included a creatinine level of 1.59. She received 
intravenous (IV) fluids and this value improved appropriately to 0.7. The documentation does not indicate the 
initial creatinine was equal to or greater than three times the baseline creatinine. The documentation does not 
indicate that the treatment ordered by the treating medical providers supported a diagnosis code of N17.9. 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 7, 2021, to September 12, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided on August 30, 2022. 
 
You asked the Plan to pay for surgical services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the records do not support these codes. 
 
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 23420 is reconstruction of complete shoulder (rotator) 
cuff avulsion. The CPT Code Manual definition of code 29823 is arthroscopy, shoulder, surgical; debridement, 
extensive, 3 or more discrete structures. The CPT Code Manual definition of code 64418 is injection, anesthetic 
agent and/or steroid; supracapsular nerve. 
 
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 surgical services. Our reviewer says that these codes do not meet criteria for payment. Our reviewer found the documentation submitted does not verify procedure codes 
23420 and 29823 Additionally, the documentation does not support an injection for post-operative pain; 
therefore, 64418 would not be billed separately from anesthesia services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical services have not been met. Therefore, we decided that the Plan does 
not have to pay for surgical services provided on August 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer implantation 
(22869). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says this service is considered 
experimental and investigational there is a lack of evidence to support that interspinous spacer devices are as 
safe and effective as the gold standard of decompression. 
 
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 Vertiflex procedure. 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 the Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex Superion interspinous spacer implantation (22869).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy and needle insertion provided on December 
15, 2022, by an OON provider. 
 
You asked the Plan to pay for physical therapy and needle insertion. You say that you are appealing based on 
medical necessity. The Plan denied your request. The Plan says the enrollee must get care from network 
providers. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physical therapy and needle insertion provided on 
December 15, 2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethasone tablets. 
 
You asked the Plan to pre-approve Dexamethasone tablets. The Plan denied your request. The Plan says the 
enrollee is not receiving chemotherapy, and this medication falls under Part D coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone tablets.   
Benefits for Dexamethasone tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that lab reports were provided, 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on February 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary. 
 
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 that the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
continued inpatient rehabilitation. The Plan denied your request. The Plan says the records do not support a 
continued stay at an IRF. 
 
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 enrollee's nursing, rehabilitation and medical needs do not 
require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. 
While the enrollee may benefit from physical and occupational therapy, the enrollee's rehabilitation needs can 
be provided in a lower intensity and alternate setting such as an in-home with services. 
 
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 IRF admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for imaging services provided on October 27, 2022, billed with codes 
93000 and 93040. 
 
You asked the Plan to pay for imaging serviced provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that these codes have a PC/TC indicator of 4 and 
codes with this indicator cannot be billed to hospital inpatients or outpatients. 
 
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. We find that the specific denial rationale offered by the Plan is not supported. 
The rules for indicator 4 say that modifier 26 or TC can't be used. These codes were not billed with either of 
these modifiers. The plan's rationale about the codes not being able to be billed to hospital inpatients or 
outpatients appear to pertain to PC/TC indicator 5. The Plan has not provided any alternate rationale. As such, 
we find that the denial of payment on this basis is not substantiated. Therefore, we decided that the Plan must 
pay for imaging services provided on October 27, 2022, billed with codes 93000 and 93040.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve joint injections identified with codes 27096, G0260. 
 
You asked the Plan to pre-approve joint injections. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
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 joint injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic low back pain due to sacroiliitis. The enrollee has been treated with 
medical therapy. There is evidence of a clinical picture that is suggestive of sacroiliac injury and/or disease. 
There are at least three positive exam findings of sacroiliac (SI) joint dysfunction present on physical exam 
such as: Patrick's test, thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test.  The enrollee has improved with medical therapy. Therefore, the enrollee does not meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of joint injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve joint injections identified with codes 27096, G0260.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed for this 
procedure. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued care with an out-of-network provider. 
 
You asked the Plan to pre-approve continued care with an out-of-network provider. You say that changing 
providers would be harmful. The Plan denied your request. The Plan says you can receive care from in-network 
providers. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued care with an out-of-network 
provider. Our reviewer says that use of the requested provider is not medically necessary. Our physician 
reviewer found breast cancer is the most common cancer in women and commonly cared for by community 
oncologists. You have received standard treatments and can receive follow-up care from in-network providers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued care with an out-of-network provider have not been met. Therefore, 
we decided that the Plan does not have to pre-approve continued care with an out-of-network provider.