Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on July 30, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says a 
corrected claim must be submitted within 1 year from the date of the initial determination or redetermination 
for any reason. 
 
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 emergency department visit was not filed until September 20, 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 an emergency department visit provided on 
July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
January 19, 2022. 
 You asked the Plan to pay for procedure code 87481 and 87653. You say that these services were medically 
necessary. The Plan denied your request. The Plan says payment for codes 87481 and 87653 is bundled into 
payment for code 87801. 
 
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 codes 
87481 and 87653 are column II codes to column I code 87801. 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 codes 87481 and 87653 billed for 
date of service January 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogenic cellular/tissue-based 
product. 
 
You asked the Plan to pre-approve allogenic product. You say that this procedure is appropriately indicated for 
the enrollee. The Plan denied your request. The Plan says this 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 allogenic product. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited large-scale, long-term, peer reviewed literature showing this request 
to be a safe or effective treatment for 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 allogenic product have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous injection of allogenic cellular/tissue-based product.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy services (77370, 77387, 
77523). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 proton beam radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no plausible reason provided in the available documentation that proton 
therapy would be more beneficial than standard therapy for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy services (77370, 77387, 77523).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee's records do not show the need for continued treatments and care that can only be given in a hospital 
setting. The records do not show the doctors expect the enrollee will get better with LTACH care and that 
hospice or comfort care is not more appropriate or preferred. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on October 20, 2022, billed 
with code 24301. 
 
You asked the Plan to pay for the services as billed. You say that it is felt that code 24301 should be paid. The 
Plan denied your request. The Plan says the records do not support the use of code 24301. 
 
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 24301 is Muscle or tendon transfer, any type, upper arm 
or elbow, single (excluding 24320-24331). 
 
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 services as billed. Our reviewer says that the billed code is not supported by the operative report. Our reviewer found the description of 24301 is for a transfer of the 
elbow/upper arm; the documentation states that the procedure was performed on the shoulder. Although there 
is a more specific code for the shoulder transfer, in this case, it appears to be included in the main procedure. 
 
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 services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services provided on October 20, 2022, billed with code 24301.
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 the enrollee has chronic respiratory failure 
secondary to severe COPD and has tried the BiPap at home in the past, but now needs home non-invasive 
ventilator as she also has chronic hypercapnia. Moreover, the device is medically necessary to prevent 
respiratory and frequent hospitalizations. The Plan denied your request. The Plan says the records show that the 
enrollee's noninvasive ventilator was ordered to be used solely in AVAPS mode, which is available in less 
invasive devices like BiPAP machines. 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 the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic hypercarbic respiratory failure from chronic obstructive pulmonary disease. The record indicates 
that the enrollee was successfully treated with BiPAP. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability. The plan has indicated coverage for such a 
device is available upon request. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
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 pay for code 99233 billed for dates of service November 16, 2021, to 
November 18, 2021. 
 
You asked the Plan to pay for code 99233. You say that the medical records support the claim as billed. The 
Plan denied your request. The Plan says code 99233 billed for dates of service November 16, 2021, to 
November 18, 2021, is not supported because the records do not support a detailed history and/or medical 
decision making of high complexity. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval 
history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination 
of care with other providers or agencies are provided consistent with the nature of the problem(s) and the 
patients and/or familys needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patients 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 code 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found the enrollee was a then 68-year-old female with a history 
of morbid obesity, diabetes mellitus with neuropathy, and chronic obstructive pulmonary disease who 
presented with bilateral foot ulcers and was admitted. The evaluation and management code billed requires a 
detailed history, a detailed examination and medical decision making of high complexity. However, the 
medical records submitted did not support a detailed history and/or medical decision making of high 
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 code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for dates of service November 16, 2021, to November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. 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 22, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve special supplemental benefits for the chronically ill (SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says that based on 
the information submitted there is no documentation that you meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition. 
 
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 SSBCI benefits. Our reviewer says that 
SSBCI benefits are reasonable and necessary for you. Our physician reviewer found the review indicates that 
you have a history of polyarteritis nodosum, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), 
congestive heart failure (CHF) and coronary artery disease (CAD). Our reviewer also found that per the 
coverage criteria, you meet the coverage criteria for SSBCI benefits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SSBCI benefits have been met. Therefore, we decided that the Plan has to pre-
approve special supplemental benefits for the chronically ill (SSBCI).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thromboendarterectomy, with or without patch graft; 
carotid, vertebral, subclavian, by neck incision (35301) and transcatheter placement of intravascular stent, 
cervical carotid artery, percutaneous; with distal embolic protection (37215), and associated inpatient 
admission. 
 
You asked the Plan to pre-approve carotid thromboendarterectomy, transcatheter carotid artery stent placement, 
and associated inpatient admission. You say that the services are medically necessary. The Plan denied your 
request. The Plan says the requested 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 carotid thromboendarterectomy, 
transcatheter carotid artery stent placement, and associated inpatient admission. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not indicate the rationale for the left-sided thromboendarterectomy, as 
the doppler imaging indicates that the vertebral artery has normal antegrade flow; the common and internal 
carotid arteries do not meet the 70% threshold presented in the Medicare criteria. In summary, carotid 
thromboendarterectomy and transcatheter carotid artery stent placement would not appear to be medically 
necessary in the management of this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of carotid thromboendarterectomy, transcatheter carotid artery stent placement, 
and associated inpatient admission have not been met. Therefore, we decided that the Plan does not have to 
pre-approve thromboendarterectomy, with or without patch graft; carotid, vertebral, subclavian, by neck 
incision (35301) and transcatheter placement of intravascular stent, cervical carotid artery, percutaneous; with 
distal embolic protection (37215), and associated inpatient admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided by a Licensed Surgical 
Assistant (LSA) on June 2, 2022. 
 
You asked the Plan to pay for the LSA services. You say that the provider was requested to assist in this 
procedure and it was medically necessary. The Plan denied your request. The Plan says the assistant used in 
this case is not a valid provider type. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
by a Licensed Surgical Assistant (LSA) on June 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CT scan, cervical spine; without contrast material 
(72125) to be performed by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network service. You say that the service is medically necessary. 
The Plan denied your request. The Plan says there are participating providers in the enrollee's network that can 
perform the CT scan. 
 
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 
the CT scan, cervical spine; without contrast material (72125) to be performed by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bed frame with mattress and related expenses (codes 
E1399 and 99199), and sales tax (S9999) purchased on October 1, 2022. 
 
You asked the Plan to pay for the bed frame with mattress and related expenses, and sales tax. The Plan denied 
your request. The Plan says the items you received are explicitly listed as not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that mattresses are only covered where hospital bed is 
medically necessary. Medicare rules also say that Medicare does not make separate payment for sales tax. 
 
We looked at the file and Medicare rules. Specifically, there is no indication that a hospital bed is necessary for 
you, and sales tax is not covered. Based on this information, we decided that Medicare rules for coverage of the 
bed frame with mattress and related expenses, and sales tax have not been met. Therefore, we decided that the 
Plan does not have to pay for the bed frame with mattress and related expenses (codes E1399 and 99199), and 
sales tax (S9999) purchased on October 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided in the Commonwealth of Australia 
on February 23, 2022. 
 
You asked the Plan to pay for dental services. You say that you are covered for up to $1,000 of dental work and 
see no reason this should not be covered. The Plan denied your request. The Plan says dental services are not 
covered outside of the United States. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States and its territories are not covered except in limited, specified circumstances. The Plan offers a 
worldwide emergency care and emergency ambulance benefit that goes beyond Medicare coverage. 
 
We looked at the file and Medicare rules. These services do not fall within Medicares coverage for items and 
services furnished outside of the United States and its territories. Additionally, the Plan does not cover dental 
services outside of the United States. Based on this information, we decided that Medicare rules for coverage of 
dental services have not been met. Therefore, we decided that the Plan does not have to pay for dental services 
provided in the Commonwealth of Australia on February 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 63047 billed for date of service August 25, 
2022. 
  You asked the Plan to pay for procedure code 63047. The Plan denied your request. The Plan says payment for 
code 63047 is bundled into payment for code 22633. 
 
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 63047 
is a column II code to column I code 22633. 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 63047 billed for date of service August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (G2212) provided on September 29, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code G2212 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code G2212. Based on this information, we decided that Medicare rules for coverage of 
the physician services have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services (G2212) provided on September 29, 2022.