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

 
We decided that the Plan does not have to pre-approve evaluation and management services with an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON evaluation and management services. You say that the current 
provider has reached the limits of their ability to treat you. You say that the requested OON provider is the only 
specialist that can evaluate and treat your scleroderma for advanced stages. The Plan denied your request. The 
Plan says there are in-network providers within a reasonable distance from you who can provide the care 
needed. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 OON evaluation and management 
services. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found the Plan is medically justified on the basis that it is offering adequate care to meet your medical 
needs through referral to a network rheumatologist. The records do not support that the complexity of your 
conditions are such that the in-network specialist the Plan referred you to would be unable to provide you with 
adequate care. The Plan has shown that they have an in-network provider who can meet the Standards of Care 
required for treatment of your condition. 
 
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 OON evaluation and management services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve evaluation and management services with an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that please review the attached information for appeal. 
The Plan denied your request. The Plan says the requested service is not reasonable and necessary. 
 
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 ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has a diagnosis of COPD and was recently hospitalized with an exacerbation, with 
venous blood gas showing partial pressure of carbon dioxide (PCO2) greater than 130. The enrollee has had a 
permanent tracheostomy since April 2022, apparently because of a previous episode of respiratory failure. One 
of the notes mentions tracheal obstruction, but there is no detail about this. The enrollee keeps the tracheostomy 
plugged, apparently even at night. There is a diagnosis of severe obesity, but weight or body mass index (BMI) 
are not provided. There is no consideration of obstructive sleep apnea. This enrollee may benefit from having 
the tracheostomy unplugged at night, and/or bilevel positive airway pressure (BiPap) at night delivered via the 
tracheostomy if it remains in place. The average volume-assured pressure support (AVAPS) mode can be 
provided with BiPap. Medicare does not cover a home ventilator when used at 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on July 20, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99223. 
 
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. 
 
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 procedure code 99223. Our reviewer says that the medical 
records do not support the billing of code 99223. Our reviewer found based on the documentation provided, the 
documented examination is not comprehensive. The medical decision making is not of high complexity. As 
such, the billing of code 99223 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested genicular nerve blocks 
are under clinical investigation with several trials underway. The services are considered experimental in nature 
and are not medically necessary at this time. 
 
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 genicular nerve blocks.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a periodic oral evaluation - established patient (D0120) provided on 
January 9, 2023. 
 
You asked the Plan to pay for the periodic oral evaluation. You say that this service was a medically necessity. 
The Plan denied your request. The Plan says that you received this service less than twelve months ago. 
 
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, we requested the Plans 2023 EOC without a response.  Therefore, 
we decided that the Plan has to pay for a periodic oral evaluation - established patient (D0120) provided on 
January 9, 2023.  
 
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 annual wellness visit (99397) provided December 19, 
2022. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial of the obstetrics and 
gynecology (OBGYN) visit. The Plan denied your request. The Plan says benefit is exhausted as pap tests and 
pelvic exams are covered once every 24 months. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the 
Plans coverage rules apply in this case.  
In this case, the CPT Code Manual definition of code 99397 is periodic comprehensive preventive medicine 
reevaluation and management of an individual including an age and gender appropriate history, examination, 
counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic 
procedures, established patient  
 
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 office visit. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our reviewer found the 
enrollee had an OBGYN routine office visit on November 18, 2021, which was paid.  Per Medicare policy 
guidelines the enrollee would not be eligible for another routine physical with the OBGYN until 2 years which 
would be November 18, 2023. The enrollee reported to the GYN for routine physical on December 19, 2022, 
and per documentation had no complaints. This enrollee is not high risk for cervical or vaginal cancer and is 
not of childbearing age with a history of an abnormal pap within the last three years. The review has 
determined that the documentation did not support the annual wellness visit coded as 99397. 
 
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 office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the annual wellness visit (99397) provided December 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on October 12, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the transport was medically necessary for this patient due to being in an altered mental state and extreme 
weakness. The Plan denied your request. The Plan says this claim does not meet criteria for the ambulance 
transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary.  
 Our physician reviewer found the transportation via ambulance from the hospital to the nursing home was not 
medically necessary. The enrollee did not require the expertise of trained personnel or the equipment available 
only on an ambulance in order to effectuate a safe transport.  Transportation could have been provided by other 
means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, 
non-emergency transport provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99224 provided on September 3, 2022. 
 
You asked the Plan to pay for procedure code 99224. You say that the medical records support the billing of 
code 99224. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99224. 
 
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 99224 is Subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused 
interval history; Problem focused examination; Medical decision making that is straightforward or of low 
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 patient is stable, recovering, or improving. Typically, 15 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
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 procedure code 99224. Our reviewer says that the medical 
records do not support the billing of code 99224. Our reviewer found based on the documentation provided, the 
history and physical represents initial services, not subsequent services. Therefore, the billing of code 99224 is 
not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99224 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99224 provided on September 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown (D2750). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
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 a 
dental crown (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no detailed information on how much the previous radiofrequency ablation 
helped with pain relief. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation of the amount of pain relief and duration of pain relief from the prior 
radiofrequency ablations. The review has determined that the enrollee did not receive proper relief from the 
first RFA to indicate the need for another one. 
 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 a repeat radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve he Intracept procedure. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has 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 he Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of the enrollee's back pain is unclear from the provided records. This 
procedure is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of he Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax, and 
pulmonary ventilation and perfusion imaging (78582) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CT scan of the thorax, and pulmonary ventilation and perfusion imaging. 
You say that you want to go to this provider. The Plan denied your request. The Plan says this provider is out-
of-network. These services can be provided in-network. 
 
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 
a computed tomography (CT) scan of the thorax, and pulmonary ventilation and perfusion imaging (78582) to 
be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated hip abduction orthosis (L1686) and 
addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each 
(L2624) provided September 28, 2021. 
 
You asked the Plan to pay for the orthosis. You say that attached are the medical records requested to process 
the claim. Please reprocess the claim. The Plan denied your request. The Plan says information is needed to 
consider this charge. 
 
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 pay for the orthosis. 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 back and right hip pain. The enrollee has been treated with medications, 
thoracic facet joint injections and bilateral sacroiliac joint injections. There is no specific clinical rationale for 
the requested hip orthosis. Given the documentation provided for review, the items/services at issue in this case 
are 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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the prefabricated hip abduction orthosis (L1686) and addition to lower extremity, pelvic 
control, hip joint, adjustable flexion, extension, abduction control, each (L2624) provided September 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastrointestinal (GI) tract imaging (91110). 
 
You asked the Plan to pre-approve GI tract imaging. The Plan denied your request. The Plan says there is no 
documentation the enrollee had both upper and lower gastrointestinal endoscopies within the past 12 months. 
 
The Plan follows Medicare rules. Medicare rules say that a wireless capsule endoscopy is indicated for 
investigating suspected small intestinal bleeding in persons with objective evidence of recurrent, obscure GI 
bleeding who have had upper and lower GI endoscopies within the past 12 months (EGD and colonoscopy) that 
have failed to identify a bleeding source. 
 
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 gastrointestinal tract imaging. Our 
reviewer says that the enrollee does not meet the coverage criteria for a gastrointestinal tract imaging. Our 
physician reviewer found the enrollee has multi-system disease, upper gastrointestinal symptoms, and chronic 
anemia with high expectation of mixed etiology. Our reviewer also found the available records neither 
demonstrate radiographic abnormalities in the small bowel, active gastrointestinal hemorrhage, nor recent 
esophagogastroduodenoscopy (EGD) and colonoscopy within the last year to warrant as medically necessary 
and reasonable a wireless capsule endoscopy at this time in lieu of higher yield endoscopic testing.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of gastrointestinal tract imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve gastrointestinal (GI) tract imaging (91110).