Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on April 20, 
2021. 
 
You asked the Plan to pay for the moderate sedation services (99153). 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. 
 
  In this case, the CPT Code Manual definition of code 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor.  Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services (99153) have not 
been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) 
provided on April 20, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. While the 
enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab can be safely 
provided at a lower intensity and alternate setting such as in a 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services rendered on May 21, 2021. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 the pathology services 
rendered on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmology services provided on December 17, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON ophthalmology services. You say that you have been seeing the 
provider at issue since 2008, and he has helped you recover your vision. You state that you would rather 
change plans than see another eye doctor. The Plan denied your request. The Plan says the doctor at issue left 
your medical group as of August 1, 2021. A referral was submitted for the visit at issue, which was denied. 
There are other network providers who could have provided the routine six-month follow up on your condition. 
 
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 the ophthalmology services provided on 
December 17, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you will not be in a safe environment if sent home. 
The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready 
for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily 
basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although 
further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent 
skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; 
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can 
receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not 
medically 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
March 16, 2021. 
 
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 there is no additional documentation supporting an additional study which was billed and 
remains denied. 
 
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 74176 is "Computed tomography, abdomen and pelvis; 
without contrast material." 
 
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 a review of the records shows a single 
computed tomography (CT) of the abdomen and pelvis. It was done on 3/16/21. The appeal is for a duplicate 
charge and should not be paid. 
 
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 additional imaging services provided to the enrollee on March 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that it is not safe for you to go home. You are heavily 
reliant on his walker and there is no one to observe you 24 hours a day. You haven't had that much therapy or 
exercise to get up and moving The Plan denied your request. The Plan says SNF care is not medically 
necessary because you can be managed at a lower level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready 
for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily 
basis. You are medically stable and can receive further rehab services at a lower level of care.  Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a skilled nursing facility. You do not have any parental 
medication; complex wound care or nutrition given via a feeding tube.  You are medically stable without any 
acute exacerbations of chronic medical problems.  Your physical function is at or near your baseline and you 
can receive services at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 8 PT visits. You say that the enrollee will benefit from additional PT 
treatment to continue working on upper extremity strength and nerve mobility. The Plan denied your request. 
The Plan says continued PT visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 8 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the provided documentation indicates that the enrollee has had prior 
therapy. The reviewer found that the documentation does not reveal that the enrollee requires the unique skills 
of a professional therapist to safely and effectively provide treatment, or that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. The reviewer found that 
the enrollee has been instructed in a home exercise program. The requested services are not part of a 
maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 8 physical therapy (PT) visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee is stable, and education has been provided. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
The file shows that 9 additional home health skilled nursing visits were requested. 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 has a medical history including diabetes mellitus, chronic lung disease and congestive heart failure 
who has been receiving home health nursing visits. She has had previous visits with home health nursing to 
educate regarding medication management, pain management, diet, household safety and medical conditions. 
There is no indication that she has a feeding tube, parental medications or complex wound care issues. There is 
no indication that she had any recent medication changes or hospitalizations. There has not been a recent 
decline in function, and she has been medically stable. Therefore, the requested home health services are not 
medically 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 home health skilled nursing services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 28, 2020. 
 
You asked the Plan to pay for the medical services. You say that these services should be treated as in-network 
and paid. The Plan denied your request. The Plan says the patient was enrolled in hospice on the date of service 
in question, so the Plan is not responsible for this bill. The patient was enrolled in hospice from March 16, 
2020, until her date of death (December 25, 2020.) 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emotional/behavioral assessment rendered on November 
4, 2021 to November 18, 2021. 
 
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 code 96127 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 96127 (brief emotional/behavioral assessment) and G0439 
(annual wellness visit). Code 96127 is a column II code with a modifier indicator of 1 when billed with column 
I code G0439. Code 96127 was not billed with an appropriate modifier to allow for separate payment. 
Therefore, we decided that the Plan does not have to pay for the emotional/behavioral assessment rendered on 
November 4, 2021 to November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service rendered on October 28, 2021. 
 
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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status 
indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for 
the special anesthesia service rendered on October 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on June 
30, 2021. 
 
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 submitted records do not indicate that two separate services were performed. 
 
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 70491 is "Computed tomography, soft tissue neck; with 
contrast material(s)." 
 
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 inaccurate codes were used. There 
was a computed tomography angiography (CTA) of the head and of the neck done on 6/30/21. The appropriate 
codes were CPT 70496 and 70498. 
 
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 additional imaging services provided to the enrollee on June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 1, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (CPT code 64633) 
and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or 
CT); cervical or thoracic, each additional facet joint (CPT code 64634). 
 
You asked the Plan to pre-approve the services. You say that it is impossible for a diagnostic medial branch 
blocks (MBB) to last six (6) months or more. You state as the blocks we have done before are diagnostic 
blocks, they should not count towards the total number of spinal procedures per year as they are not designed to 
have lasting effect. You state the repeated diagnostic blocks were very helpful in stopping the enrollee's pain 
and you believe radiofrequency ablation (RFA) will further help their pain and improve their activities of daily 
living. The Plan denied your request. The Plan says the requested procedure session will exceed the allowed 
limit of no more than two (2) sessions per region of the enrollee's spine in twelve (12) months. The Plan states 
a session is defined as all spinal procedures performed on the same date of service. The Plan states the 
enrollee's neck and upper back make up one spinal region, and their lower back and tailbone make up the other 
spinal region. 
 
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 physician reviewer 
found the request exceeds the utilization criteria of the LCD. Therefore, the request is deemed 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); cervical or thoracic, single facet joint (CPT code 64633) and destruction by neurolytic 
agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each 
additional facet joint (CPT code 64634).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second claim for emergency department (ED) evaluation 
and management (EM) services and moderate sedation provided on January 6, 2021, billed with codes 99285 
and 99152. 
 
You asked the Plan to pay for the second claim for the ED EM services and sedation. You say that you feel this 
must be due to a billing error because you were only seen once on this date. The Plan denied your request. The 
Plan says a claim for these exact services was paid. A second claim was received and denied as duplicate 
correctly. The Plan indicates that contact was made with the provider who agreed that this claim was sent in 
error, and no charges related to it are outstanding. 
 
The Plan must follow Medicare rules. The rules say that exact duplicate claims are denied by Medicare but can 
be appealed. 
 
Review of the file shows that this was indeed a duplicate claim for the same services that were reimbursed on a 
separate claim. This claim was denied correctly, and it is noted that you do not owe any money for the services 
at issue. Therefore, we decided that the Plan does not have to pay for a second claim for emergency department (ED) evaluation and management (EM) services and moderate sedation provided on January 6, 2021, billed 
with codes 99285 and 99152.