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

 
We decided that the Plan does not have to pay for procedure code 99214 billed for June 1, 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 code 99214 is 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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
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 these services. Our reviewer says that procedure code 99214 
is not supported. Our reviewer found the submitted documentation does not support that the enrollee's 
presenting problems required medical decision making of moderate complexity. 
 We looked at this coder'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 procedure code 99214 billed for June 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation (PVA) coded 
as 22511 and 22514. 
 
You asked the Plan to pre-approve the surgical procedure. You say that you feel it is appropriate to perform an 
L1 vertebral augmentation for what is considered a chronic but still painful compression fracture. The Plan 
denied your request. The Plan says procedure to stabilize the L1 compression fracture is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic back pain. The magnetic resonance imaging (MRI) shows 
severe multilevel spinal stenosis and mild L1 compression fracture that may be subacute. The pain generator is 
not identified in this case. Kyphoplasty is not medically needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the percutaneous vertebral augmentation (PVA) coded as 22511 and 22514.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Blatchford Echelon foot (L5981, L5968).

You asked the Plan to pre-approve a Blatchford Echelong foot. You say that the requested foot is medically necessary to achieve safer ambulation for the enrollee. The Plan denied your request. The Plan says that the request for a K3 foot exceeds the enrollee's need. The Plan also says that it does not meet the Medicare criteria of reasonable and necessary.

The Plan follows Medicare rules. Medicare rules say that a flex-walk system or equal is covered for beneficiaries whose functional level is 3 or above.

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 Blatchford Echelong foot. Our reviewer says that a K3 Echelon prosthetic foot is medically necessary. Our physician reviewer found the documentation provided does support the use of the requested transtibial prosthesis with K3 components. The enrollee is noted to have the potential to be a K3 level ambulator based on the prosthetic and medical documentation. The reviewer found that the enrollee requires a prosthesis for mobility and performing daily activities and requires a new prosthetic socket due to changes in his residual limb after revision surgery. The enrollee is currently ambulating with the prosthesis with the assistance of walking stick and can ambulate with variable cadence and on uneven terrain. An amputee mobility predictor scoring form indicated that the enrollee scored at 42, which is a K3 level. The reviewer found that the enrollee is noted to have normal motor strength and range of motion in the lower extremities, besides below the transtibial amputation. Therefore, the reviewer found that a K3 Echelon prosthetic foot (L5981, L5968) is 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 a Blatchford Echelong foot have been met. Therefore, we decided that the Plan has to pre-approve a Blatchford Echelon foot (L5981, L5968).

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 procedure code S9328 billed for date of service May 2, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service May 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 04, 2021, 
through July 09, 2021, and billed with secondary diagnosis code G93.41. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis code G93.41-Metabolic encephalopathy is supported by the records. The Plan denied your 
request. The Plan says the documentation submitted does not support secondary diagnosis of G93.41. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code G93.41-Metabolic 
encephalopathy. 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 documentation does not support the secondary 
diagnosis of G93.41-Metabolic encephalopathy. Our physician reviewer found the member presented with a 
urinary tract infection (UTI) and lethargy. The member was confused on admission day up until discharge day. 
The member was treated for urinary tract infection (UTI) with antibiotics and discharged to a skilled nursing 
facility. The member had baseline dementia. There was no clinical or laboratory evidence of metabolic 
encephalopathy, therefore diagnosis code G93.41-Metabolic encephalopathy is not the appropriate secondary 
diagnosis.  
 
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 July 04, 2021, through July 09, 2021, and billed with secondary 
diagnosis code G93.41.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for housing services provided on February 18, 2022 to 
November 4, 2022. 
 
You asked the Plan to pay for the housing services. You say that this stay was medically necessary. The Plan 
denied your request. The Plan says housing services is not a covered benefit. The services were not provided by 
a network provider or pre-approved. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the housing services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for housing 
services provided on February 18, 2022 to November 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December 8, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the member had multiple exams done on 
this date of service. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service December 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested ventilator. You say that the enrollee has been using the 
ventilator will good results. The Plan denied your request. The Plan says the level of support needed by the 
enrollee does not require a ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer 
says that the requested ventilator is not shown to be medically reasonable and necessary. Our physician 
reviewer found the enrollee has had previous hospitalizations for respiratory failure, and arterial blood gas 
results have been consistent with acute on chronic hypercarbic respiratory failure. The enrollee has had a home 
ventilator for the last few months and reportedly is doing well with it. The enrollee has been using the device at least 4 hours per day. This enrollees ventilatory support needs could be met with bilevel positive airway 
pressure (BiPAP) with average volume-assured pressure support (AVAPS). Medicare does not cover a home 
ventilator when used with settings that can be provided with BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045-26-77 billed for date of service June 
24, 2022. 
 You asked the Plan to pay for procedure code 71045-26-77. You say that the claim was billed correctly and 
should be paid The Plan denied your request. The Plan says payment for code 71045-26-77 is bundled into 
payment for code 71046. 
 
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 
71045-26-77 is a column II code to column I code 71046. 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 71045-26-77 billed for date of 
service June 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 1, 2022, to 
August 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 1, 2022, to 
August 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December 8, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that multiple exams were done on this date of 
service. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied.  
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service December 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a referral for toenail clipping to a podiatrist. 
 
You asked the Plan to pre-approve the services. You say that you are partially blind and need someone to cut 
your nails. The Plan denied your request. The Plan says that this is not covered. 
 
Tufts must follow Medicare rules. The rules say that routine foot care is not a covered Medicare benefit unless 
you have diabetic foot disease or some other condition that makes professional care of your feet medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Part C Plan was correct in denying the request to pre-approve the services. Our reviewer says 
that the requested services are medically reasonable and necessary. Our physician reviewer found that the 
enrollee does indeed have a covered condition for the trimming of toenails. It is well established that this 
patient is suffering with bilateral lower extremity atherosclerosis. Both skin and toenail changes are 
documented in the progress note dated 11/14/22. Medicare advises that routine foot care may be covered when 
the patient has a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet. 
This has been documented well by the podiatrist, and physical manifestations of this patients lower extremity 
atherosclerosis are noted.. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a referral for toenail clipping to a podiatrist.  
 
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 lab services provided on August 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for transportation related services provided from  
May 20, 2022, to July 12, 2022. 
 
You asked the Plan to reimburse you for transportation related services. You say that the travel services were 
for visits to maintain active on the transplant list. The Plan denied your request. The Plan says the travel 
services were not transplant related visits and are not eligible for the travel and lodge services benefit. 
 
The Plan contract covers lodging and transportation costs for you and a companion for transplant related care. 
 
We looked at the file and the Plans rules. The file shows that the transportation related services were not 
related to your transplant visits. Based on this information, we decided that the Plans rules for coverage of 
transportation related services have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for transportation related services provided from May 20, 2022, to July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (77002, J7324, 20610) provided on November 15, 
2022. 
 
You asked the Plan to pay for the injections. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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, we have confirmed that code 77002 
is an add-on code and has not been billed with an appropriate primary procedure code. Codes J7324, and 20610 
were not billed with valid laterality modifiers for the diagnosis codes billed. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
injections (77002, J7324, 20610) provided on November 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 
30, 2022. 
 You asked the Plan to pay for procedure code 76705. 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 76705 is bundled into 
payment for code 76981. 
 
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 76705 
is a column II code to column I code 76981. 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 76705 billed for date of service November 30, 
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 the services are medically necessary for the enrollee to regain maximum function. The Plan denied your request. The Plan says the enrollee's needs can be met in a lower 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including physical or occupational therapy. There is not a reasonable expectation that the enrollee 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.