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

 
We decided that the Plan has to pay for the outpatient office visit (99215) and computed tomography (CT) 
bone mineral density study (77078) provided on August 16, 2022. 
 
You asked the Plan to pay for the outpatient office visit and CT bone mineral density study. You say that the 
provided documentation shows medical necessity for both of these codes. The Plan denied your request. The 
Plan says that the outpatient office visit charge is incidental to another service. The Plan also says the CT bone 
mineral density study does not meet the applicable coverage requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 outpatient office visit and CT bone 
mineral density study. Our reviewer says that the outpatient office visit and CT bone mineral density study 
were medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has a 
history of aggressive prostate cancer and has received hormonal therapy. The office visit was to discuss various 
follow-up and treatment options and should be reimbursed. Our reviewer found that the history of prostate 
cancer and hormonal therapy with androgen deprivation is a valid reason for bone densitometry since there is a 
predisposition to the development of osteoporosis with this type of therapy. Our physician reviewer also found 
that the CT bone mineral density study (77078) should be reimbursed. 
 
Medicare rules also 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. Specifically, there are no 
active edits between the outpatient office visit (99215) and any of the codes billed on this date of service. We 
find that the Plan has not substantiated their denial of payment for the outpatient office visit in this case. 
 
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 outpatient office visit and CT bone mineral density study have been met. 
Therefore, we decided that the Plan has to pay for the outpatient office visit (99215) and computed tomography 
(CT) bone mineral density study (77078) provided on August 16, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on September 19, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was coded correctly. The Plan denied 
your request. The Plan says the code is not acceptable as a primary diagnosis. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 01270 was billed with primary diagnosis code I70.92. This diagnosis code has a code 
first note, indicating that this code is not permitted to be used as a principal diagnosis code. 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 anesthesia services provided on September 19, 2022.
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 a SNF admission is medically necessary. The Plan 
denied your request. The Plan says that records show the enrollees condition does not meet the requirements 
for coverage of SNF services.  
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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: 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 August 2, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. 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 August 2, 2022, billed 
with code 99153.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing (81455) billed for date of service March 30, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that this test is not covered. 
 
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. Specifically, the Plan has not provided any argument to clarify why this is a non-
covered test, nor has the Plan provided any citation or evidence to support their denial. The Plan's denial is not 
substantiated in this case. Therefore, we decided that the Plan has to pay for laboratory testing (81455) billed 
for date of service March 30, 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 pre-approve tubing with heating element (A46004), a positive 
airway pressure disposable filter (A7038), a positive airway pressure non-disposable filter (A7039), a 
continuous positive airway pressure (CPAP) full face mask (A7030) and headgear used w/ positive airway 
pressure device (A7035) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve CPAP device supplies. You say that you did not know that the requested 
provider was a non-contracted provider. The Plan denied your request. The Plan says the requested rendering 
provider is not contracted with the Plan. You must use network providers to get your medical care and services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
tubing with heating element (A46004), a positive airway pressure disposable filter (A7038), a positive airway 
pressure non-disposable filter (A7039), a continuous positive airway pressure (CPAP) full face mask (A7030) 
and headgear used w/ positive airway pressure device (A7035) to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for office visits (code 99214) provided from January 21, 2022 to 
August 10, 2022.  
 
You asked the Plan to pay for the office visits. You say that there was no procedure done on these claims that 
would make them incidental to another service. You say that this provider is not a Radiologist, he is a 
Rheumatologist. The Plan denied your request. The Plan says that this charge is incidental to another service. 
 
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. Specifically, the Plan has not provided a coding rule, a Medicare rule or a Plan 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for office visits (code 99214) 
provided from January 21, 2022 to August 10, 2022.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 12,2021, 
through December 15,2021, and billed with diagnosis code I21.A1. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis I21.A1 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of I21.A1. 
 
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 I21.A1 (Myocardial infarction 
type 2). 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 member was admitted to inpatient care to rule out a stroke. 
While the documentation discussed a diagnosis of type II non-ST elevated myocardial infarction, the clinical 
evidence did not support the secondary diagnosis I21.A1 (Myocardial infarction type 2. A Type 2 myocardial 
infarction is caused by a mismatch between myocardial oxygen supply and oxygen demand typically in the 
presence of coronary artery disease. The member was noted to be in no acute distress, no chest pain, and no 
shortness of breath. Therefore, the secondary diagnosis code I21.A1 (Myocardial infarction type 2) is 
inappropriate. Our physician reviewer found the member was treated for a stroke and hypertensive urgency. 
The members troponin rose and fell during the hospital stay. The electrocardiogram showed atrial fibrillation 
with premature ventricular contraction, 1st degree AV block, PACs but no evidence of ischemia. The 
echocardiogram showed grade 2 diastolic dysfunction but no wall motion abnormalities. Therefore, without 
sufficient objective evidence of type II myocardial infarction, this secondary diagnosis is not sufficiently 
supported in the provided 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 on December 12,2021, through December 15,2021, and billed with 
diagnosis code I21.A1.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service May 29, 
2022. 
 You asked the Plan to pay for procedure code 99285. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99285 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99285 billed for date of service May 29, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the radical excision of bursa (25115) provided on June 21, 2022. 
 
You asked the Plan to pay for the radical excision of bursa (25115). You say that procedure code 25115 is a 
distinct and separately identifiable procedure warranting separate reimbursement. You say that the operative 
report is attached, and the claim should be reprocessed for additional payment. The Plan denied your request. 
The Plan says that procedure code 25115 is not supported by the medical records submitted. 
 
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 25115 is radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, 
Tbc, or other granulomas, rheumatoid arthritis); flexors. 
 
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 radical excision of bursa (25115). Our reviewer says that 
procedure code 25115 is supported by the documentation. Our reviewer found a separate radical flexor 
tenosynovectomy was required to thicken the tenosynovial tissue of the index, middle, ring, and little fingers. 
 
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 radical excision of bursa (25115) have been met. Therefore, we decided that 
the Plan has to pay for the radical excision of bursa (25115) provided on June 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit billed with code 99213 for September 9, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that post-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code 99213 was related to and billed within 90 days of 
major surgical procedure 52601 on July 20, 2022. Payment for code 99213 is included in the global surgical 
package for code 52601. Therefore, we decided that the Plan does not have to pay for the office visit billed 
with code 99213 for September 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on October 27, 
2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an LSO is covered when specific criteria are met. 
 
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 
services were not medically necessary. Our physician reviewer found the documentation does not support that 
the LSO is needed to facilitate healing following and injury to the spine or related soft tissues. The 
documentation does not support that the LSO is needed to facilitate healing following a surgical procedure on 
the spine or related soft tissues. There is no documentation of a physical examination evidence of weak spinal 
muscles and/or a deformed spine. The criteria for coverage are not met and the LSO was not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (LSO) rendered on October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig (A9282). 
 
You asked the Plan to pre-approve a wig. You say that you are having chemotherapy for your breast cancer and 
will have drug-induced androgenic alopecia. The requested wig is necessary. The Plan denied your request. 
The Plan says wigs are not covered under any condition. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig (A9282).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for pathology services (88305) billed for date of service July 28, 2022. 
 
You asked the Plan to pay for pathology services. You say that this service was medically necessary, and you 
believe the referring provider is in-network with the enrollee's Plan. The Plan denied your request. The Plan 
says that this service was provided out-of-network and the enrollee's Plan does not cover this out-of-network 
service. 
 
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. Medicare rules also say that a contract provider is an agent of the plan. Services and referrals given 
by a contract provider are considered approved by the plan unless notice is provided that the services will not 
be covered. The plan follows these rules. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided any evidence to support that the referring 
physician in this case is not the enrollees primary care provided and is not within the Plans network. It is the 
Plans responsibility to clearly support any reason for denial. There is insufficient evidence to show that the 
enrollee was not referred for pathology services by a contract provider. The file does not show that the Plan 
provided notice that this service would not be covered. Under Medicare rules, this means that the pathology 
services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for pathology 
services (88305) billed for date of service July 28, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 (5 units) billed for date of service May 
31, 2022. 
 
You asked the Plan to pay for 5 units of procedure code 87481. You say that that these services were necessary 
and are supported as billed. The Plan denied your request. The Plan says these services are not supported in the 
medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure 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 to pay for 5 units of procedure code 87481 Our 
reviewer says that this service is not supported as billed by the records provided. Our physician reviewer found 
that three units of 87481 are supported, rather than the five units billed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 units of procedure code 87481 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 87481 (5 units) billed for date of service May 31, 2022.