Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered prepared meals. 
 
You asked the Plan to pre-approve home delivered prepared meals. You say that you have congested heart 
failure and should be placed on the Medicare meals after discharge. The Plan denied your request. The Plan 
says the enrollees inpatient stay was due to bilateral lower leg cellulitis so they dont meet the plans criteria 
for home-delivered meals. 
 
The Plan must follow Medicare rules. The rules say that the Plans may offer meals as a supplemental benefit 
immediately following surgery or an inpatient hospital stay, or for certain chronic conditions. The Plan offers a 
home-delivered meals supplemental benefit. The Plan covers home-delivered meals following discharge from a 
hospital as an inpatient due to congestive heart failure. 
 
 
 We looked at the file and Medicare rules. While you were discharged from an inpatient hospital stay, your 
inpatient stay was not for congestive heart failure. Based on this information, we decided that the Plans rules 
for coverage of home delivered prepared meals have not been met. Therefore, we decided the Plan does not 
have to pre-approve home delivered prepared meals.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on April 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis codes are mismatched. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with mismatched diagnosis 
codes. There is a more appropriate diagnosis code to support the services as rendered. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the office visit rendered on April 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection provided on May 25, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were diagnosed with 
COVID-19 and have a history of blood clots. You also say they wanted to make sure there would be no 
problems with your lungs and breathing issues. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a total of $66.05 for an injection, which is 20% of the allowed amount ($330.25 
allowed amount x 20% coinsurance = $66.05). An injection falls within the Medicare Part B prescription drugs 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the injection provided on May 
25, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy office visit provided on March 30, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy office visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
  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 psychotherapy office visit provided on March 30, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Osteocel. 
 
You asked the Plan to pre-approve Osteocel. You say that the records provided support the need for Osteocel. 
The Plan denied your request. The Plan says the clinical value and effectiveness of Osteocel in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 Osteocel. Our reviewer says that 
Osteocel is not considered medically reasonable and necessary in this case. Our physician reviewer found 
Osteocel remains experimental in cases of lumbar fusion. More research is needed for use of Osteocel. Iliac 
crest autograft is the gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Osteocel have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Osteocel.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on May 11, 2022. 
 
You asked the Plan to pay for the x-ray. You say that the enrollee was not on hospice for this service. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the chest x-ray (71045) provided on May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an assisted living facility (ALF) admission. 
 
You asked the Plan to pre-approve the AFL admission. You say that the enrollee needs to be placed in an ALF. 
You say that the enrollee has tried to escape the home. You also say there is an inability to maintain safety at 
home. The Plan denied your request. The Plan says the enrollee does not require the level of care than an ALF 
provides. 
 
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 
 
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 AFL admission. Our reviewer says 
that the requested ALF admission is not medically necessary. Our physician reviewer found the provided 
documentation indicates improved nighttime safety and not yet having tried going to the PACE Center 5 days a 
week. Therefore, the reviewer found that an ALF admission is not medically reasonable or 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 the AFL admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an assisted living facility (ALF) admission.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service August 29, 2020. 
 
You asked the Plan to pay for code 99285. You say that this service was billed correctly. The Plan denied your 
request. The Plan says code 99285 is not supported by the medical record because only a moderate complexity 
of medical decision-making was performed by the physician. Therefore, the service was paid at the rate for 
code 99284. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 code 99285 Our reviewer says that code 
99285 is not supported in the medical record. Our reviewer found the enrollee was a then, a 73 year-old male 
with a history of coronary artery disease, hypertension, abdominal aortic aneurysm, and peripheral artery 
disease who presented to the emergency room after a fall. He had a head injury with a forehead laceration. He 
was evaluated with a history and physical exam, laboratory studies and computed tomography scans of the 
head and cervical spine. The laceration was repaired, and he was given IV fluids. He was observed and 
discharged home. Code 99285 was not supported in the medical record because there was no medical decision 
making of high complexity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service August 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sclerotherapy procedure (36470). 
 
You asked the Plan to pre-approve the sclerotherapy procedure. You say that the service is medically 
necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a sclerotherapy is covered when 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 sclerotherapy procedure. Our 
reviewer says that this procedure is not medically necessary. Our physician reviewer found the documentation 
shows there is saphenous vein reflux. It should be noted that the treatment in question addresses the less 
symptomatic leg. 
 
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 sclerotherapy procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sclerotherapy procedure (36470).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion or replacement of peripheral or gastric 
neurostimulator pulse generator or receiver, direct or inductive coupling (64590) and percutaneous 
implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555). 
 
 
You asked the Plan to pre-approve the Sprint peripheral nerve stimulator (PNS) system. You say that you are 
requesting reconsideration of the decision to deny. The enrollee had a PNS trial and received over 80% relief. 
 The Plan denied your request. The Plan says the records was not provided that the enrollee meets the criteria. 
The SPRINT Peripheral Nerve Stimulator (PNS) System does not fit the Medicare definition of an implanted 
peripheral nerve stimulator 
 
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 Sprint peripheral nerve stimulator 
(PNS) system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this would be considered experimental/ investigational. 
Therefore, the request is deemed 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 Sprint peripheral nerve stimulator (PNS) system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the insertion or replacement of peripheral or 
gastric neurostimulator pulse generator or receiver, direct or inductive coupling (64590) and percutaneous 
implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the 
abdomen and pelvis. 
 
You asked the Plan to pre-approve a CTA of the abdomen and pelvis. You say that this imaging is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have 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 a CTA of the abdomen and pelvis. Our 
reviewer says that the requested imaging service is not medically reasonable and necessary. Our physician 
reviewer found the documentation does not support the medical necessity of the study in question. Foremost, 
there is nothing in the medical records suggesting that the treating physician is interested in obtaining a CT 
scan of the abdomen and pelvis. The patient has a history of an aortic duplex in the recent past that 
demonstrated no evidence of abdominal aortic aneurysm (AAA) and the only more recent mention of imaging 
of the abdomen was to obtain an abdominal duplex as a screening study for AAA. There is no evidence in the 
medical record of any other issue with respect to the abdomen or its vessels. 
 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 CTA of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the abdomen and 
pelvis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (37244, 36247, 36248) provided on November 
24, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. In this case, payment for the requested services (36247, 37244) is included in the global 
surgical payment for the procedure (49440) provided on November 22, 2021. 
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, we have confirmed that code 36248 is an add-on code and has not been 
billed with an appropriate primary procedure code. As code 36247 is not payable, the add-on code is also not 
payable on the Based claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the services (37244, 36247, 36248) provided on November 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) and services provided at a 24-
hour facility, in addition to basic services (99053) billed on October 31, 2021. 
 
  You asked the Plan to pay for critical care services (99291) and services provided at a 24-hour facility, in 
addition to basic services (99053). You say that the attached medical records support the claim as originally 
billed and no coding changes are required. You say that the records support the level of service assigned and 
the services were medically necessary. The Plan denied your request. The Plan says procedure codes 99291 is 
not supported by the medical records submitted and procedure code 99053 is not separately payable. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. The CPT Code Manual definition of code 99053 is 
service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. 
 
We find that CPT codes 99291 and 99053 are not supported in the medical record. Specifically, the records do 
not support critical care services of 30-74 minutes was performed. In addition, procedure code 99053 has a 
status indicator of B on the Physician Fee Schedule. This means that procedure code 99053 is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of critical care services 
(99291) and services provided at a 24-hour facility, in addition to basic services (99053) have not been met. 
Therefore, we decided that the Plan does not have to pay for critical care services (99291) and services 
provided at a 24-hour facility, in addition to basic services (99053) billed on October 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation (64624) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is not enough evidence to show that this procedure is safe 
and that it works well for knee pain. 
 
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 requested services are not considered medically reasonable and necessary in this case. This procedure is 
considered an experimental. Our physician reviewer found that the enrollee's condition does not meet criteria 
for coverage of these services. 
 
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 ablation (64624) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex device. 
 
You asked the Plan to pre-approve the Coflex device. You say that the requested Coflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Coflex device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Coflex device. Our reviewer says 
that the requested Coflex device is not medically necessary. Our physician reviewer found the Coflex device is 
experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Coflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Coflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service December 28, 2021. 
 
You asked the Plan to pay for code 99223. You say that code 99223 is supported in the medical record. The 
Plan denied your request. The Plan says code 99223 is not supported in the medical record because this was not 
a high complexity evaluation and management service. 
 
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 visit, witg medical decision 
making of a high complexity (70 minutes average). 
 
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 99223. Our reviewer says that code 99223 is not 
supported in the medical record. Our reviewer found the progress notes received failed to meet the required key 
components when billing for Initial hospital care of high complexity evaluation and management service. Specifically, there was no medical decision-making that is of high complexity because the following 
documentation would be needed (two of three below must be met or exceeded): Extensive number of diagnoses 
or management option Extensive amount and/or complexity of data to be reviewed, and High risk of significant 
complications, morbidity and/or mortality. 
 
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 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service December 28, 2021.