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

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on 
May 26, 2021. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable 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. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, this code was billed with 
place of service 21 (inpatient hospital). However, the documentation shows that the enrollee was outpatient for 
this date of service. Based on this information, we decided that Medicare rules for coverage of the initial 
hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
initial hospital care services coded 99223 provided on May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72070 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 72070. You say that the enrollee had multiple procedures on the 
date in question. The Plan denied your request. The Plan says payment for code 72070 is bundled into payment 
for code 72072. 
 
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 72070 
is a column II code to column I code 72072. 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 72070 billed for date of service March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on April 12, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for wound care supplies. You say that per Medicare guidelines, these supplies are a 
separately billable expense that does not require separate authorization and have not been included in any other 
billing to treat the wounds described in the attached medical record documentation. The Plan denied your 
request. The Plan says this provider is not a network provider with the Plan. The Plan has also determined that 
these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound care supplies provided on April 12, 2022, 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on 
February 13, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you called for 
emergency help and you were provided with something to eat and an intravenous of glucose, which made you 
stable. You say that you had the right to decide that that you wanted to stay at home with your husband rather 
than being transported to the emergency room. The Plan denied your request. The Plan says the ambulance 
benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicare 
covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 13, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
provided on February 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vitrectomy chair. 
 
You asked the Plan to pre-approve a vitrectomy chair. You say that this is medically necessary for the complete 
recovery of the eye surgery. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a vitrectomy chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78803 billed for date of service December 9, 
2021. 
 You asked the Plan to pay for procedure code 78803. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 78803 is bundled into payment for code 71275. 
 
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 78803 
is a column II code to column I code 71275. 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 78803 billed for date of service December 9, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ILUX procedure provided on November 27, 2019. 
 
You asked the Plan to pay for the procedure. You say that in the process of reconciling your billing system with 
the providers scheduling system you discovered charges that were omitted for the enrollee and are respectfully 
requesting reconsideration of services rendered for payment. The Plan denied your request. The Plan says 
Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 
calendar year from the date the services were furnished. 
 
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 procedure was not filed until December 17, 2021. 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 ILUX procedure provided on November 27, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne Heme (F1Heme) comprehensive genomic 
profiling (81455) provided on January 10, 2022. 
 
You asked the Plan to pay for F1Heme testing. You say that this service was medically necessary and is 
supported in the medical records. The Plan denied your request. The Plan says genetic testing procedures 
submitted with cod 81455 are unlikely to impact therapeutic decision-making in the clinical management of an 
enrollee and will be denied as not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that certain codes are automatically denied as not 
medically necessary as they are unlikely to impact therapeutic decision making in the clinical management of a 
patient.  
 
We looked at the file and Medicare rules. Code 81455 was listed under the Group 3 Paragraph of Article 
A56199 at the time of services. This means that this service is considered automatically denied as not 
medically necessary. Therefore, we decided that the Plan does not have to pay for FoundationOne Heme 
(F1Heme) comprehensive genomic profiling (81455) provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural injection (64483). 
 
You asked the Plan to pre-approve the injection. You say that the requested injection is medically necessary. 
The Plan denied your request. The Plan says the criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injection (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using the same scale for at 
least three months. 
 
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 injection. Our reviewer says that the 
requested injection is not medically necessary. Our physician reviewer found the medical records provided do 
not indicate the enrollee had more than 50% pain relief for at least 3 months after her prior epidural steroid 
injection. The reviewer also found that the provided records do not specifically address the issue of what is 
unique about this enrollee's condition to require the requested epidural steroid injection therapy for more than 
12 months Therefore, the reviewer found that the requested injection is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural injection (64483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service March 4, 
2022. 
 
You asked the Plan to pay for procedure code G0453. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code G0453 is bundled into payment for code 95955. 
 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 G0453 
is a column II code to column I code 95955. 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 G0453 billed for date of service March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stair lift you purchase on February 17, 2022. 
 
You asked the Plan to pay for the stair lift. You say that you were told this was approved and your doctor told 
you that you had to have this item. The Plan denied your request. The Plan says stair lifts are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for the stair lift you purchase on February 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs exceed the capability 
of a skilled nursing or subacute rehabilitation facility. The Plan denied your request. The Plan says we will 
continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition 
is stable for transfer to an alternate level of care (such as a skilled nursing facility), or until the clinical 
circumstances change such that LTACH may be reconsidered. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on August 30, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve electrolysis epilation (17380) and office visit (99205). 
 
You asked the Plan to pre-approve the physician services. You say that you are currently in the process of 
transitioning. You say that you need laser hair reduction of the face. You say that this is really messing with 
your mental health. You also say that you feel this should be covered. The Plan denied your request. The Plan 
says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 physician services. Our reviewer 
says that the requested electrolysis epilation is considered medically reasonable and necessary in this case. Our 
physician reviewer found the reviewer found that the hair growth is impacting your psychological state. The 
reviewer found that controlling this is part if the approved medical therapy. The reviewer also found that hair 
removal should not be viewed as an aesthetic issue but rather an integral part of your therapy. Therefore, the 
reviewer found that the requested service is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the physician services have been met. Therefore, we decided that the Plan has to 
pre-approve electrolysis epilation (17380) and office visit (99205).  
 
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 lab testing services provided on January 17, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing identifies underlying determinants of 
pain. The Plan denied your request. The Plan says the test is not food and drug administration (FDA). The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. We find that the testing is not supported in the medical record. Specifically, 
the records show that the testing assesses the likelihood for contributing factors of pain. There are insufficient 
records to show the testing was ordered based on signs or symptoms. Medications should be provided based on 
the presence of a diagnosis and should be adjusted based on a response to the medication. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab testing services provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on January 12, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that a fixed height hospital bed (E0250, E0251, E0290, 
E0291, and E0328) is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a semi-electric hospital bed. Our 
reviewer says that the services are medically necessary. Our physician reviewer found clinical documentation 
from the provider states that you require frequent changes in position that would not be otherwise achieved, as 
well as requirement for changes in head of bed elevation. Thus, a semi-electric hospital bed 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 semi-electric hospital bed have been met. Therefore, we decided that the Plan 
has to pre-approve a semi-electric hospital bed.  
 
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 a Freestyle Libre continuous glucose monitor (CGM) 
for the enrollee. 
 
You asked the Plan to pre-approve a CGM. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
continuous glucose monitor (CGM) for the enrollee.