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

 
We decided that the Plan does not have to pay for procedure codes 99231 and 99232 billed for date of service 
August 24, 2022, and August 31, 2022. 
 
You asked the Plan to pay for procedure codes 99231 and 99232. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claims were submitted with incorrect taxonomy. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99231 and 99232 are not supported in the medical record. Specifically, the claims 
were submitted with an incorrect taxonomy. This means the claims are not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99231 and 99232 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99231 and 99232 billed for 
date of service August 24, 2022, and August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37227, 37252, 37253, 75716, and 75625 
billed for date of service September 7, 2022. 
 
You asked the Plan to pay for procedure codes 37227, 37252, 37253, 75716, and 75625. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed 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. 
 
We find that CPT codes 37227, 37252, 37253, 75716, and 75625 are not supported in the medical record.  
 
 Specifically, the operative report did not include documentation of an open or percutaneous endovascular 
revascularization of unilateral femoral or popliteal artery(s), with transluminal stent placement(s) and 
atherectomy, including angioplasty within the same vessel, when performed; therefore, code 37227 cannot be 
verified. 
 
The operative report did not include documentation of an intravascular ultrasound (noncoronary vessel) during 
diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; 
initial noncoronary vessel (Listed separately in addition to code for primary procedure); therefore, code 37252 
cannot be verified. 
 
The operative report did not include documentation of an intravascular ultrasound (noncoronary vessel) during 
diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; 
each additional noncoronary vessel (Listed separately in addition to code for primary procedure); therefore, 
code 37253 cannot be verified. 
 
The operative report did not include documentation of a radiological supervision and interpretation an 
angiography for bilateral extremity studies; therefore, code 75716 cannot be verified. 
 
The operative report did not include documentation of a radiological supervision and interpretation of an 
abdominal aortography by serialography; therefore, code 75625 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 37227, 37252, 
37253, 75716, and 75625 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 37227, 37252, 37253, 75716, and 75625 billed for date of service September 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection of venous blood by venipuncture (36415) 
travel allowance for collection of specimens drawn from homebound or nursing homebound patient (P9604) 
provided October 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that your billing department was understaffed 
due to decreased hours to prevent the spread of COVID-19 within your office. You would appreciate an 
extension of the normal timely filing timelines, since you've been under extraordinary circumstances. The Plan 
denied your request. The Plan says the claim was received past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until December 1, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the collection of venous blood by venipuncture (36415) travel allowance for collection of specimens drawn from homebound or nursing homebound patient (P9604) provided 
October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) study of the 
cervical spine. 
 
You asked the Plan to pre-approve the MRI of the cervical spine. You say that the services are medically 
necessary. The Plan denied your request. The Plan says medical records do not show that there was any 
indication of a trial of conservative treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 pre-approve the MRI of the cervical spine. Our 
reviewer says that the MRI is not medically necessary. Our physician reviewer found there is no documentation 
of a trial and failure of physical therapy services for the enrollee's neck pain. 
 
 
 
 
 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 MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) study of the cervical spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided 
from August 31, 2022, to September 27, 2022. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that this device was medically 
necessary. The Plan denied your request. The Plan says this device is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a water circulating heat pad with pump will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a water circulating heat pad with pump (E0217) provided from August 31, 2022, to 
September 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for family psychotherapy services provided from 
April 12, 2022, to July 12, 2022. 
 
You asked the Plan to reimburse you for family psychotherapy services. The Plan denied your request. The 
Plan says a mental health counselor is not a covered Medicare provider. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to reimburse you for family psychotherapy services provided from  
April 12, 2022, to July 12, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 63710 billed for date of service October 3, 2022. 
 
You asked the Plan to pay for procedure code 63710. You say that the service at issue has been billed correctly. 
The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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's denial rationale states that payment for procedure code 
63710 is included in the payment for code 63709 because code 63710 is a Column II code to Column I code 
63709. However, we found that it is code 63710 that is the more comprehensive (Column I) code. It is the 
Plan's responsibility to support its denial with evidence. In this case, the denial is not supported, so we must 
find in your favor. Therefore, we decided that the Plan has to pay for procedure code 63710 billed for date of 
service October 3, 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 additional power wheelchair accessories (E2300, 
E2322, E2331). 
 You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the items or services still do not meet the coverage criteria. 
 
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 accessories. Our reviewer says that 
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation indicates the wheelchair has been authorized to have a joystick and 
any additional attendant controls 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 the accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2300, E2322, E2331).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on September 19, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says these items are not covered outside of the home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device and appliance was used in an ambulatory surgical center. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliance 
provided on September 19, 2022.
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 are appealing the denial. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 that you do not require services at the LTACH that are not available at the acute care 
hospital where you currently receiving care. All medically necessary care is being provided in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are not 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77065-26-LT-76 billed for date of service 
November 9, 2022. 
 You asked the Plan to pay for procedure code 77065-26-LT-76. You say that the claim was billed correctly and 
should be paid. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 77065 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 77065-26-LT-76 billed for date of service November 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Phesgo. 
 
You asked the Plan to pre-approve Phesgo. 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 must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Phesgo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Phesgo is not FDA-
approved for the enrollees diagnosis. The use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Phesgo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Phesgo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is not medically 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 a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that a diagnosis of COPD is mentioned in the record, but there are no pulmonary function tests to confirm. There is 
no diagnosis of thoracic restrictive disease or neuromuscular disease. There is no documentation of chronic 
carbon dioxide (CO2) retention with an arterial blood gas (ABG) done while stable. The enrollee may benefit 
from BiPAP during sleep. The record does not show that this has been tried and failed as an outpatient. The 
average volume-assured pressure support (AVAPS) mode can be provided via 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation procedures (64635, 64636). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested radiofrequency ablation 
is a medical necessity for the enrollee. The Plan denied your request. The Plan says the request 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 radiofrequency ablation. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has had prior diagnostic MBBs and RFA at different levels. The 
present request is for RFA bilaterally at L2-L3 and L3-L4 without diagnostic MBBs first. However, the rules 
require 2 sets of diagnostic MBBs before RFA. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation procedures (64635, 64636).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you have been progressing in rehabilitation this past 
week and want to continue. The Plan denied your request. The Plan says that that you no longer require daily 
skilled 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation shows that you have had recent functional/clinical 
changes. The clinical documentation shows that your evaluating therapists recommend continued daily skilled 
therapies and you have not yet reached your past level of function and still require maximum assistance with 
mobility and self-care thus continued daily skilled services on an inpatient basis in a skilled nursing facility is 
medically appropriate. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
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. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 enrollee has shoulder osteoarthritis. 
Euflexxa is not approved by the Food and Drug Administration (FDA) for this diagnosis. The use of hyaluronic 
acid injections for shoulder arthritis remains experimental in nature. The services are therefore 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 pre-approve Euflexxa.