Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided from March 9, 2022, 
to April 8, 2022. 
 
You asked the Plan to pay for the infrared therapy. You say that you would like this claim to be processed 
correctly. The Plan denied your request. The Plan says infrared therapy is considered not reasonable and 
necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light 
and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the 
symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory 
neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026) provided from March 9, 2022, to April 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have had a Visa/credit since last year, and 
are wondering if your primary care physician has sent the information. The Plan denied your request. The Plan 
says based on the information submitted, there is no documentation that you meet the coverage 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on October 21, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes are valid for reimbursement purposes. 
The Plan denied your request. The Plan says the diagnosis code is not acceptable as the primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that the services provided were billed with diagnosis code R65.10. There is a code first note at the 
manifestation code, indicating that this is not an appropriate primary diagnosis code. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for the emergency room services provided on October 21, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing services provided on October 11, 2021. 
 
You asked the Plan to pay for the laboratory testing services provided. You say that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says that the billed code doesn't meet Medicare 
NCD/LCD criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan's denial rationale states that the unique identifier is missing; however, 
we were able to locate the number on the claim form provided. Since no other rationale was provided, we find 
that the denial of payment is not substantiated. Therefore, we decided that the Plan has to pay for laboratory 
testing services provided on October 11, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle foot orthosis (L1971) provided on November 7, 
2022. 
 
You asked the Plan to pay for the ankle foot orthosis. You say that the medical records provided support the 
need for the ankle foot orthosis. The Plan denied your request. The Plan says the delivery ticket does not 
include the specific item description shipped therefore payment is not supported at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that the proof of delivery ticket must include a 
description of the item(s) being delivered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ankle foot orthosis have not been met. Therefore, we decided that the Plan does not have to pay 
for an ankle foot orthosis (L1971) provided on November 7, 2022.
Appeal type: Supplemental Benefit
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. You say that you do not understand why this benefit is 
being denied if you have chronic conditions. The Plan denied your request. The Plan says that based on the 
information submitted there is no documentation that you meet the criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the records do not support that the Plan made multiple attempts to 
obtain medical records from the provider for this case. The records also show that an attestation from the 
provider was sent to the Plan, but this attestation was not provided with this case. This means that the Plan has 
not provided a valid reason for denying payment of the SSBCI benefits. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Sensor. The Plan denied your request. The Plan says 
the enrollee does not require insulin three or more times daily. 
 
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 
the Freestyle Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 Sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have 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 based on the 
information submitted there is no documentation that you meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI benefits have been met. 
Medical records were not provided for this case. The record shows that the Plan attempted to obtain this 
information, but it was not received. Without medical records, we are unable to determine if you meet the 
required criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration for the denial of an LTACH admission. You say the enrollee would benefit from admission to 
an LTACH to regain a maximum/prior level of functioning and continue a multidisciplinary approach to care. 
The Plan denied your request. The Plan says the enrollee does not meet the guidelines for care in 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 enrollee appears to be improving and should only require short-term additional 
acute care services that can safely be provided at the current facility until appropriate for a lower level of care. 
There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to the LTACH would not be clinically advantageous and completion of treatment at 
the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service September 3, 2022, 
and September 4, 2022. 
 
You asked the Plan to pay for code 99233. You say that these services were urgently needed and medically 
necessary. The Plan denied your request. The Plan says the medical records do not support this code. The 
medical records do not support a detailed interval history and 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 inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. 
 
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 in the medical record. Our reviewer found in this case, the documentation supported a detailed 
history, an expanded problem-focused exam, and straightforward medical decision-making. There is a more 
appropriate code to report for service provided. 
 
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 September 3, 2022, and September 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 12 physical therapy (PT) visits on top of 
the 23 visits the plan has approved. 
 
You asked the Plan to pre-approve the additional 12 PT visits. You say that the services are necessary for you 
to improve your strength and range of motion. The Plan denied your request. The Plan says you should be able 
to transition to a home education program with the total approved visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the medical records from the provider do not address your response to 
therapy and the indication for continued therapy based on your response. Continued PT services cannot be 
recommended 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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an additional 12 physical therapy (PT) visits on top of the 23 visits the plan has approved.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had hip replacement, and you need help as you 
are unable to perform daily activities on your own. The Plan denied your request. The Plan says the IRF 
services requested do not meet the requirements for approval. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service August 22, 
2022. 
 
You asked the Plan to pay for the billed service. You say that the nerve block was performed separately from 
the general anesthesia. The Plan denied your request. The Plan says an anatomical modifier was not appended. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 64447 is injection(s), anesthetic agent(s) and/or steroid; 
femoral nerve. 
 We find that CPT code 64447 is not supported. Specifically, the claim does not include a modifier that 
specifies where on the body the procedure was performed. Based on this information, we decided that 
Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 64447 billed for date of service August 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93247 billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for the billed services. You say that good faith services were rendered. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
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 93247 external electrocardiographic recording for more 
than 7 days up to 15 days by continuous rhythm recording and storage; scanning analysis with report. We find 
that CPT code 93247 is not supported in the medical record. Specifically, the records do not include monitoring 
documentation for the date of service at issue. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 93247 billed for date of service June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service October 1, 2022. 
 
You asked the Plan to pay for code 99233. You say that the medical records support payment for this code. The 
Plan denied your request. The Plan says code 99233 is not supported by the medical record. The records don't 
support a detailed interval history and 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 inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. 
 
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 in the medical record. Our reviewer found the provided records contain insufficient interval history. The medical decision making is not new, acute, active or 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 date of service October 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78830 billed for date of service May 18, 
2022. 
 You asked the Plan to pay for procedure code 78830. You say that the procedure codes are billed with the 
appropriate modifier. The Plan denied your request. The Plan says payment for code 78830 is bundled into 
payment for code 79445. 
 
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 78830 
is a column II code to column I code 79445. 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 78830 billed for date of service May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service February 6, 2022. 
 
You asked the Plan to pay for code 99223. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says code 99223 is not supported by the medical record. The medical 
records do not support 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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: A comprehensive history; A 
comprehensive exam; and Medical decision making of high complexity. 
 
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 by the medical record. Our reviewer found the enrollee was a then 74 year old female with a history of dementia, hypertension, peripheral vascular disease, hyperlipidemia, bladder cancer, overactive bladder, 
gastroesophageal reflux disease, iron deficiency anemia, and hypothyroidism who presented to the emergency 
room February 6, 2022, with hematemesis. This initial hospital care evaluation and management code requires 
a comprehensive history, a comprehensive examination and medical decision making of high complexity. 
However, the medical records submitted did not support 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 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service February 6, 2022.