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

 
We decided that the Plan does not have to pay for codes 37231, 37252, 37253, and 75710, billed for November 
12, 2021. 
 
You asked the Plan to pay for codes 37231, 37252, 37253, and 75710. The Plan denied your request. The Plan 
says the billed codes 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 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 codes 37231, 37252, 37253, and 75710. Our reviewer says 
that the use of codes 37231, 37252, 37253, and 75710, is not supported by the records provided. Our reviewer 
found that in order for a vessel to be treated, the documentation must state that a catheter/intervention was 
inserted into that vessel. The documentation does not specify that a catheter was inserted into a tibial/peroneal 
artery and that a stent/arthrectomy with or without angioplasty was performed (36231), with IVUS (37252, 
37253), in that vessel. There is no ultrasound report stating that any vessels were examined. The descriptions the provider gave were generic and not specific to this enrollee and his anatomy. The documentation also does 
not state that angiography of an extremity was performed (if these codes were supported, the angiography is 
included in 37231). 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 37231, 37252, 37253, and 75710 have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 37231, 37252, 37253, and 75710, billed for November 12, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood count services provided on September 19, 2021. 
 
You asked the Plan to pay for the blood count services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee was still covered under hospice for this date of service. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 5, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the blood count 
services provided on September 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator (E1390) and unlisted 
special service, procedure or report (99199) purchased April 5, 2022. 
 
You asked the Plan to pay for the oxygen equipment. You say that you called the Plan and was told that you are 
eligible for reimbursement of $3,484.32. Neither the doctor nor the Plan told yo that you needed a doctor's 
order or that you needed to get equipment from a durable medical equipment supplier. The Plan denied your 
request. The Plan says the enrollee purchased the durable medical equipment directly from non-participating 
supplier. Original Medicare only covers the rental of oxygen equipment and accessories. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay 
for the portable oxygen concentrator (E1390) and unlisted special service, procedure or report (99199) 
purchased April 5, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 8, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider is a 
mental health counselor and not eligible for payment by the health Plan or original Medicare. 
 
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 pay for psychotherapy provided on September 8, 2022.
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. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of LTACH service is correct. 
 
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 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
pneumatic appliance, chest (E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the requested 
garment is needed for treatment of lymphedema. The Plan denied your request. The Plan says you have not had 
a 4-week trial of the basic pneumatic compression device and you do not have truncal or abdominal 
lymphedema described on exam, which is a requisite for the coverage of the advanced pneumatic compression 
device as noted in the LCD. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a pneumatic appliance, chest (E0657).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 36 orthoptic vision therapy visits. 
 
You asked the Plan to pre-approve an additional 36 orthoptic vision therapy visits. You say that the enrollee 
has a history of convergence insufficiency and brain trauma and requires additional orthoptic vision therapy. 
The Plan denied your request. The Plan says the member has completed the 12 allowed visits and should be on 
a continuing home program. 
 
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 an additional 36 orthoptic vision 
therapy visits. Our reviewer says that an additional 36 orthoptic vision therapy visits is not considered 
medically reasonable and necessary in this case. Our physician reviewer found that while orthoptic vision 
therapy can be an important component of the treatment of convergent insufficiency, the duration of treatment 
has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional 36 orthoptic vision therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an additional 36 orthoptic vision therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from August 12, 2022, to August 
14, 2022. 
 
You asked the Plan to pay for inpatient services. You say that these services were medically reasonable and 
necessary. The Plan denied your request. The Plan says this claim cannot be paid as the primary procedure is 
never covered according to Medicare rules. 
 The Plan must follow Medicare rules. Medicare rules say that the MCE examines the type of patient and 
procedures performed to determine if the services are covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of inpatient services have not been met. Specifically, the primary procedure for this care, identified 
with code 08U9XKZ, is indicated as a procedure that is never covered by the MCE. Therefore, we decided that 
the Plan does not have to pay for inpatient services provided from August 12, 2022, to August 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77431 billed for date of service May 10, 
2022. 
 
You asked the Plan to pay for procedure code 77431. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 77431 is bundled into payment for 
code 77301. 
 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 77431 
is a column II code to column I code 77301. 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 77431 billed for date of service May 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882 billed for date of service June 30, 
2022. 
 
You asked the Plan to pay for procedure code 76882. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 76882 is bundled into payment for code 93970. 
 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 76882 
is a column II code to column I code 93970. 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 76882 billed for date of service June 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
April 26, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the billed codes are invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service April 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of authorization for IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is not shown to require 15 hours per week of rehabilitation services and 
regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as skilled nursing facility or sub-acute rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
23, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service September 23, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 44625 provided on December 20, 2021. 
 
You asked the Plan to pay for procedure code 44625. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code 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. 
 
We find that CPT code 44625 is not supported in the medical record. Specifically, code 44625 is inclusive to 
the primary procedure, code 44160 which was also billed. Based on this information, we decided that Medicare 
rules for coverage of procedure code 44625 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 44625 provided on December 20, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to make additional payment for the ambulance transportation provided on 
November 3, 2021. 
 
You asked the Plan to make additional payment for the ambulance transportation. You say that it is felt that 
additional payment is due from the Plan. The Plan denied your request. The Plan says that the primary payer 
reimbursed more than the Plan would have, meaning that the Plan is not required to make any additional 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that for services paid on a fee schedule, the lowest 
amount calculated via one of the three equations listed in the Medicare rules section determines the amount of 
secondary payment due from Medicare, or from the Medicare Advantage plan.  
 
We looked at the file and Medicare rules. Below are the results of the three calculations used to determine 
secondary payment: 
 
1. Total actual charge ($1340.52) less the amount paid by the primary ($534.02) equals $806.50; 
2. Total payable by the Plan without primary payer is fee schedule amount ($470.14) less Plan cost sharing ($0) 
as no information regarding Medicaid coverage was provided equals $470.14; 
3. Primary payer allowable, as this is higher than the Medicare allowable ($954.02) less the primary payment 
($534.02) equals $420. 
 
Since the lowest of these three amounts is $420, this is what the Plan must pay for these services. Based on this 
information, we decided that Medicare rules for coverage of the ambulance transportation have been met. 
Therefore, we decided that the Plan has to make additional payment for the ambulance transportation provided 
on November 3, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement rendered on September 20, 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 services are included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that all additional medical or surgical services required of 
the surgeon during the postoperative period of the surgery are included in the global surgical package.  
 
We looked at the file and Medicare rules. Procedure code 11042 was related to and billed within 90 days of 
major surgical procedure 15946 billed on September 20, 2022. Payment for code 11042 is included in the 
global surgical package. Therefore, we decided that the Plan does not have to pay for the debridement rendered 
on September 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the criteria for admission to SNF have not 
been met. 
 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair climbing wheelchair lift. 
 
You asked the Plan to pre-approve a stair climbing wheelchair lift. 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 a stair climbing wheelchair lift. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that a stair climbing wheelchair lift exceeds the enrollee's medical needs as there is 
insufficient evidence in the documentation that this device will be safe and effective for this 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 a stair climbing wheelchair lift have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a stair climbing wheelchair lift.
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. You say that all attending physicians have agreed that 
the member is stable for transfer to LTACH. You also say that they have determined that he requires prolonged 
and intensive skilled services that are not available at a lower level of care. The Plan denied your request. The 
Plan says because of the lack of complex medical needs for over a month or more, and the lack of need for 
daily physician supervision for this relatively stable member they are unable to approve the request for the 
member to be admitted to an LTACH. 
 
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 medical records do not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH 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.