Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from July 14, 2022 to  
October 13, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the psychotherapy. You say that this provider is in-network. The Plan denied 
your request. The Plan says there are in-network providers available who can provide the treatment you need. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided from July 14, 2022 to October 13, 2022, 
by an out-of-network provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for allograft, structural, for spine surgery only (List separately in addition 
to code for primary procedure) provided to the enrollee on June 20, 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. 
 
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 20931 is "Allograft, structural, for spine surgery only (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 enrollee was being treated for 
radiculopathy of the lumbar region. She underwent an image-guided partial L2, L3, L4, L5 laminectomies and 
bilateral L2-3, L3-4, L4-5, and L5-S1 foraminotomies; posterior L4-5 pedicle screw instrumentation and 
fusion; O-arm mediated spinal stereotaxy; intraoperative monitoring on 6/20/22. The procedure detail cites the 
L4-5 facet joints were then decorticated and a mixture of Osteocel and demineralized bone matrix was placed 
in these posterior L4-5 facet decorticated surfaces to accomplish a posterior fusion mass. This supports that an 
allograft was utilized. Therefore, the records do support that CPT 20931: Allograft, structural, for spine surgery 
only (list separately in addition to code for primary procedure) was rendered in this case. 
 
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 
allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) provided 
to the enrollee on June 20, 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: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper denture (D5110) and a lower denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures broke, and you need new 
ones. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the dentures are not covered by the Plan. 
 
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 pre-approve an 
upper denture (D5110) and a lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral genicular nerve blocks (64624 x 2). 
 
You asked the Plan to pre-approve the injections. You say that the enrollee needs this. The Plan denied your 
request. The Plan says the requested services are considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the injections have been met. 
Specifically, the file does not include any medical records to support that the services are medically necessary. 
Therefore, we decided that the Plan does not have to pre-approve bilateral genicular nerve blocks (64624 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standby service (99360) provided on August 29, 2022. 
 
You asked the Plan to pay for the physician service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says standby services are not payable to physicians. 
 
The Plan must follow Medicare rules. Medicare rules say that standby services are not payable to physicians.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physician service have not been met. Therefore, we decided that the Plan does not have to pay 
for the standby service (99360) provided on August 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external mobile cardiovascular telemetry with 
electrocardiographic recording (procedure codes 93228 and 93229) provided to the enrollee on August 30, 
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) codes 93228 and 93229 remain 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 the denied codes is: 
 
CPT 93228: 
 
External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real 
time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG 
triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; 
review and interpretation with report by a physician or other qualified health care professional  
CPT 93229: 
 
External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real 
time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG 
triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; 
technical support for connection and patient instructions for use, attended surveillance, analysis and 
transmission of daily and emergent data reports as prescribed by a physician or other qualified health care 
professional 
 
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 there is no supportive evidence 
that the ordering practitioner documented any standard, non-mobile cardiac telemetry ambulatory 
electrocardiogram monitoring. There is insufficient documentation to support these codes. 
 
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 external mobile cardiovascular telemetry with electrocardiographic recording (procedure codes 
93228 and 93229) provided to the enrollee on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99212 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 99212. You say that a full podiatric workup was involved, so this 
service should be paid. The Plan denied your request. The Plan says payment for code 99212 is bundled into 
payment for code G0127. 
 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 99212 
is a column II code to column I code G0127. 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 99212 billed for date of service July 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for selective catheter placement and moderate sedation services 
(procedure codes 36215 and 99153) provided to the enrollee on May 5, 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 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 the denied codes is: 
 
CPT 36215: 
 
Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a 
vascular family 
 
CPT 99153: 
 
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 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 four units of CPT 36215 are not 
supported. The record states that selective catheterization was performed in 3 first order thoracic or 
brachiocephalic arteries. In the remaining first order arteries, the catheter was advanced into second and third 
order arteries. According to CPT rules, selective vascular catheterization should be coded to include 
introduction and all lesser order selective catheterization used in the approach. 
 
We looked at this coder's review, the file, and Medicare rules. Additionally, 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. 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 selective catheter 
placement and moderate sedation services (procedure codes 36215 and 99153) provided to the enrollee on May 
5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. 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 August 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the new patient office visit provided on 
July 6, 2022. 
 
You asked the Plan to waive the cost sharing for the office visit. You say that this visit should be covered in 
full. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan says that you must pay your $150 
deductible which applies to all in and out-of-network services besides preventative services, emergency room 
visits, emergency ambulance services, and urgent care services, and a $20 copayment after the deductible is 
met for each Medicare-covered primary care doctor visit (including telehealth services and urgently needed 
services). 
 You have been asked to pay a cost-share of $42.36 for the office visit ($22.36 deductible + $20 copayment = 
$42.36). The item or service you asked the Plan to waive the cost sharing for falls within the 
physician/practitioner services, including doctors office visits benefit category. 
  
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible which 
applies to physician/practitioner services, including doctors office visits. This cost sharing is a contractual 
obligation that had not been met at the time the office visit was received on July 6, 2022. Therefore, we decided 
that the Plan does not have to waive the cost sharing for the new patient office visit provided on July 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 3, 2022, 
through June 7, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided were not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights.  In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not 
cross two midnights or more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) after falling at home. He reported 
neck and left rib pain. He reported not eating well due to chewing difficulty, not wearing his dentures. He  
reported urinary frequency, dysuria. The enrollee also reported chronic tingling in his feet and weakness on his 
left side from a previous stroke. His vital signs were significant for an episode of hypotension which improved 
with fluid administration. He had leukocytosis, right bundle branch block (RBBB) without ischemic changes in 
the electrocardiogram. The computed tomography (CT) scan of the spine was negative, and the CT scan of the 
ribs showed no fracture. He was treated with antibiotics for a suspected urinary tract infection. Due to the low 
complexity and low severity of this presentation, it was not expected that the enrollee would require hospital 
services that would likely have crossed two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. 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 acute inpatient hospital care provided from June 3, 2022, through June 7, 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. You say that you need this level of care. The Plan denied your 
request. The Plan says your rehabilitation needs do not require an intensive team approach medically necessary 
care may be provided safely in a different level of care. 
 
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 there is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF.  
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on September 20, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the Plan should not have recouped payment 
because your records show that the patient was only in hospice from October 20, 2021, to December 13, 2021. 
The Plan denied your request. The Plan says Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 We confirmed that the enrollee actually enrolled in hospice on December 21, 2020. The enrollee ended 
Medicare Hospice benefits on September 19, 2021. The services in question were provided before the end of 
that month. Therefore, we decided that the Plan does not have to pay for ambulance services provided on 
September 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
25, 2021, to June 2, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the removal of the diagnosis codes and change in DRG is based on lack of supporting clinical evidence from the medical record provided and not based solely 
on coding guidelines. 
 
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.   
 
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 services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the enrollee has Parkisonism and bipolar, schizoaffective, and major 
depressive disorders who was treated in the hospital. However, records report the patient's baseline includes 
some forgetfulness, unstable mood, occasional poor relating. Workup did not reveal any metabolic 
abnormalities. Therefore, the diagnosis of toxic and metabolic encephalopathy is not sufficiently supported in 
the documentation.  
 
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 to the enrollee from May 25, 2021, to June 2, 2021.