Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multi-axial ankle, additional socket insert, and above-
knee knee/hip disarticulation positional rotation unit for a lower limb prosthesis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that prosthetic accessories are 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation from the physician 
does not indicate why a multi-axial ankle is necessary. The enrollee was already approved for a socket insert. 
The requested items exceed the enrollee's needs and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a multi-axial ankle, additional socket insert, and above-knee knee/hip disarticulation 
positional rotation unit for a lower limb prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), power seat elevation system (E2300), expandable 
controller (E2377), and harness (E2313). 
 
You asked the Plan to pre-approve an electronic connection, power seat elevation system, expandable 
controller, and harness. You say that the services are necessary. The Plan denied your request. The Plan says 
based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchairs and accessories are 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 pre-approve an electronic connection, power seat 
elevation system, expandable controller, and harness. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found the requested electrical accessories are not medically necessary as you 
do have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, power seat elevation system, expandable controller, 
and harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), power seat 
elevation system (E2300), expandable controller (E2377), and harness (E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
19, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), electronic connection 
between wheelchair controller and two or more power seating system motors (E2311), power seat elevation 
system (E2300), and lateral hardware (K0108 x2). 
 
You asked the Plan to pre-approve an expandable controller, electronic connection, power seat elevation 
system, and lateral hardware. You say that the services are necessary. The Plan denied your request. The Plan 
says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchairs and accessories are 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 pre-approve an expandable controller, electronic 
connection, power seat elevation system, and lateral hardware. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found provided records document that the enrollee is modified 
independent for grooming and hygiene thus indicating he has adequate upper extremity strength and function to 
operate the wheelchair's power options with their own switches. The requested power seat elevation feature is 
statutorily non-covered as it serves no primary medical purpose. The lateral hardware (K0108 x2) is already 
included in the approved lateral supports. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, electronic connection, power seat elevation system, 
and lateral hardware have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
expandable controller (E2377), electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), power seat elevation system (E2300), and lateral hardware (K0108 x2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drug services billed with code J3490 for July 
28, 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 intra-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code J3490 is related to and was billed on the same day as 
minor surgical procedure billed with code 62321. Payment for code J3490 is included in the global surgical 
package. Therefore, we decided that the Plan does not have to pay for the unclassified drug services billed with 
code J3490 for July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital care billed with codes 99223 and 99239 for 
January 28, 2022, to February 25, 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 procedure codes 99223 and 99239 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. The definition of code 99239 is hospital discharge day management; more than 30 minutes. 
 
We find that CPT codes 99223 and 99239 are not supported in the medical record. Specifically, there is no 
comprehensive history and medical decision making of high complexity to support code 99223. There is no 
documentation of hospital discharge day management of more than 30 minutes to support code 99239. 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 hospital care billed with codes 99223 and 
99239 for January 28, 2022, to February 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service October 29, 2021. Therefore, we decided that the Plan does not have to pay for the dental services on October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the alginate dressings provided on August 30, 2022, by an out-of-network (OON) provider.

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 rendered by an out-of-network provider without prior authorization.

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 alginate dressings provided on August 30, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that you and the enrollee feel LTACH is the best treatment plan due to change in diagnosis. The Plan denied your request. The Plan says they will continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to an alternate level of care, such as skilled nursing facility (SNF), or until the clinical circumstances change such that LTACH may be reconsidered.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lodging for infusion therapy provided from August 29, 2022, to September 28, 2022.

You asked the Plan to pay for the lodging for infusion therapy. You say that you were required to obtain lodging within one hours travel time, and your lymphoma required to you isolate yourself to prevent infection. You also say that you were under constant care for 28 days. The Plan denied your request. The Plan says travel and lodging expenses are covered only under specific conditions. The Plan also says infusion therapy is not included and therefore reimbursement for lodging in this circumstance is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that in any circumstance in which an MA plan provides transplant services at a more distant location, the MA plan must provide reasonable accommodations for the enrollee and a companion while in the distant location for medical care.

We looked at the file and Medicare rules. Specifically, the record shows that chimeric antigen receptor (CAR)-T cell infusion is not chemotherapy, and you did not receive any transplant services. Based on this information, we decided that Medicare rules for coverage of the lodging for infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the lodging for infusion therapy provided from August 29, 2022, to September 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on date of service July 26,2022.

You asked the Plan to pay for the single unit of code 75710. You say that this should be paid as billed. The Plan denied your request. The Plan says this was not coded correctly.

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 75710 is a column II code to column I code 75710-51-XU, a radiological supervision and interpretation of a unilateral extremity angiography in additions to intervention procedure for service provided; however, 75710 was billed with a modifier.

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 single unit of code 75710. Our reviewer says that CPT 75710-51-XU does not meet criteria because the Operative Report does not support modifier XU. Our reviewer found the operative report describes angiography; however an intervention was performed, which includes radiological services to perform to the procedure. Open and percutaneous interventional vascular procedures include operative angiograms and/or venograms which shall not be separately reported as diagnostic angiograms/venograms.

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 single unit of code 75710. have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on date of service July 26,2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0426, A0425) provided on June 20, 2022.

You asked the Plan to pay for ambulance services. You say that these services were necessary and the enrollee did not have a choice in providers. The Plan denied your request. The Plan says these services should be billed directly to Original Medicare.

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 ambulance services (A0426, A0425) provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested third level facet injection coded as 64495 
and the requested anesthesia code as 00630. 
 
You asked the Plan to pre-approve the requested third level facet injection coded as 64495 and the requested 
anesthesia code as 00630. You say that the requested third level facet injection coded as 64495 and the 
requested anesthesia code as 00630 are medically necessary. The Plan denied your request. The Plan says the 
requested third level facet injection coded as 64495 and the requested anesthesia code as 00630 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 the requested third level facet injection 
coded as 64495 and the requested anesthesia code as 00630. Our reviewer says that the requested third level 
facet injection coded as 64495 and the requested anesthesia code as 00630 are not medically necessary. Our 
physician reviewer found the enrollee is with chronic low back pain due to lumbar spondylosis without 
myelopathy or radiculopathy. The record sent by his provider indicates the enrollee has had back pain for many 
years despite conservative treatment with medications, ice/heat, physical therapy, rest, and injections since 
August 2022. A Magnetic resonance imaging (MRI) shows facet arthropathy. His provider has recommended 3 
level facet injections under anesthesia. 
 
The review has determined that the Plan approved two levels of facet joint injections (CPT codes 64493 and 
64494). The requested third level facet joint injection (CPT 64495) is not medically reasonable or necessary.  
In addition, the requested anesthesia service (CPT 00630) is 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 requested third level facet injection coded as 64495 and the requested 
anesthesia code as 00630 have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the requested third level facet injection coded as 64495 and the requested anesthesia code as 00630.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (64628 and 64629).

You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the 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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure. Therefore, the request is deemed not medically reasonable and 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 the intracept procedure (64628 and 64629).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 18, 2022.

You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done 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 September 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 a Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertilfex 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.