Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651), and a 
segmental appliance for the leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device, and a segmental appliance for the leg. You 
say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a pneumatic compression device can be covered if 
certain 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 pneumatic compression device, and a 
segmental appliance for the leg. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found the records in this case do not document one or more venous stasis ulcer(s) or that the ulcer(s) 
have failed to heal after a six-month trial of conservative therapy directed by the treating practitioner. Records 
do not document conservative treatment that included re-assessments with detailed measurements, obtained in 
the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the 
various trials and therapy, with bilateral comparisons where appropriate. 
 
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 pneumatic compression device, and a segmental appliance for the leg have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0651), and a segmental appliance for the leg (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 provided on August 25, 2021. 
 
You asked the Plan to pay for code 99223. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the service billed is 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. 
 
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 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit.  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 99223. Our reviewer says that the documentation does 
not support the code billed. Our reviewer found the enrollee has a medical history including diabetes mellitus 
and Parkinson's disease with a recent placement of a deep brain stimulator who was transferred to the hospital 
from an outside facility with fevers and diabetic ketoacidosis. At the time of admission, the member was no 
longer in DKA and was noted to be medically stable. His laboratory studies had normalized. The plan of care 
was for continuation of empiric antibiotics, specialty consultation and a lumbar puncture. Additional work up 
of possible esophageal disease was to be considered. The decision making was not noted to be of high 
complexity. Therefore, the code billed is not supported. 
 
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 provided on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain fused to high noble metal tooth # 6 
(D6240), and retainer crown - porcelain fused to high noble metal tooth #'s 5 and 7 (D6750). 
 
You asked the Plan to pre-approve codes D6240 and D6750. You say that this service is medically necessary. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers codes D6240 
and D6750 when the services are medically necessary and reasonable.  
 
 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 codes D6240 and D6750. Our reviewer 
says that the requested services are not medically necessary. Our physician reviewer found the services do not 
meet the criteria for coverage. Coverage for a fixed bridge may be considered to replace a single missing 
maxillary anterior tooth if there are no posterior teeth missing. In this case there are multiple missing teeth in 
the maxilla ((#'s 2, 3, 6, 11, 12, 14 and 15). This service does not meet the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of codes D6240 and D6750 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a pontic - porcelain fused to high noble metal tooth # 6 (D6240), and retainer 
crown - porcelain fused to high noble metal tooth #'s 5 and 7 (D6750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar epidural steroid injection (LESI), level not 
specified (62323). 
 
You asked the Plan to pre-approve the injection services. You say that the enrollee has limited options as the 
enrollee has chronic kidney disease stage III and should not use nonsteroidal anti-inflammatory drugs. The Plan 
denied your request. The Plan says the records do not support that the criteria has 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 the injection services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, there is no documentation of use of an objective pain scale or functional 
assessment at the enrollees current baseline.  In addition, there is no radiological image-based diagnostic 
testing supporting one of the following: lumbar, cervical or thoracic radiculopathy, radicular pain and/or 
neurogenic claudication due to disc herniation, osteophyte or osteophyte complexes, severe degenerative disc 
disease, producing foraminal or central spinal stenosis. The review has determined that the ESI 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the lumbar epidural steroid injection (LESI), level not specified (62323).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve sclerotherapy. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are > than 4 
mm in diameter and if the patient remains symptomatic after a six-week trial of conservative 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 sclerotherapy. Our reviewer says that 
the requested sclerotherapy is not medically reasonable and necessary. Our physician reviewer found that there 
is no assessment provided either by pulse examination or noninvasive studies. Additionally, it is unclear from 
the documentation that all the veins being considered for sclerotherapy are greater than 4 mm. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for dates of service from 
September 9, 2022, to September 11, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the provided records do not support the service 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. 
 
In this case, the CPT Code Manual definition of code 99233 is: Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99233. Our reviewer says that the code at 
issue does not meet criteria for payment. Our reviewer found that the enrollee had a stable clinical course and 
did not require complex decision making, as the enrollee was on standard meds and improving without side-
effects. There was no detailed history and no detailed physical exam. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 billed for dates of service from September 9, 2022, to 
September 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 5, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must be 
submitted to the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the services provided on April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for August 5, 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 records do not support the billing of code 99223. 
 
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 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit.  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for these services. Our reviewer says that the records do not 
support the billing of code 99223. Our reviewer found the provided medical records do not document medical 
decision making of high complexity with an extensive number of diagnoses or management options and an 
extensive amount and complexity of data reviewed and high risk of complication. The records document that 
35 minutes were spent with the enrollee/family and/or coordination of care. Typically, 70 minutes are spent at 
the bedside and on the enrollee's hospital floor or unit for CPT code 99223. 
 
We looked at this coder'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 pay for procedure code 99223 billed for August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99305 provided on August 24, 2022. 
 
You asked the Plan to pay for code 99305. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code 99305 is initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient's 
facility floor or unit.  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 99305. Our reviewer says that the documentation does 
not support the code billed. Our reviewer found the enrollee was evaluated for a surgical wound on the right 
foot. In this case, the medical records submitted did not support a comprehensive history and a comprehensive 
examination. Therefore, code 99305 is not supported. 
 
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 99305 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99305 provided on August 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transesophageal echocardiogram (TEE) (93312). 
 
You asked the Plan to pre-approve a TTE. You say that this imaging is medically necessary. The Plan denied 
your request. The Plan says the requested TEE 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 TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had a recent TTE indicating a valve with moderate aortic valve stenosis. Clinical 
guidelines do not support carrying out a TEE in this setting. In summary, there is no supportive evidence for 
the medical necessity of a TEE in this this enrollee's clinical management. 
 
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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transesophageal echocardiogram (TEE) (93312).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code S5000 billed for date of service March 29, 2022. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says the service is not 
payable by Medicare. 
 
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 S5000 is prescription drug, generic. We find that CPT 
code S5000 is not payable by Medicare. Therefore, we decided that the Plan does not have to pay for code 
S5000 billed for date of service March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (31645) provided on October 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is inclusive to 
code 32663. 
 
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 31645 is "Bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 31645 is 
not supported by the records provided. Our reviewer found that code 31645 is not supported as a separately reportable diagnostic procedure. The medical record states it was a therapeutic bronchoscopy and evaluated the 
surgical field, which doesn't meet NCCI criteria as a separately reportable procedure. The bronchoscopy is 
included in the more extensive procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (31645) provided on October 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a sacral nerve stimulator (64590).  
You asked the Plan to pre-approve a sacral nerve stimulator. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request 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 sacral nerve stimulator. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee must have had a successful test stimulation in order to support 
subsequent implantation. The documentation does not support that in this case the enrollee has had a 50 percent 
or greater improvement through test stimulation. 
 
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 sacral nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of a sacral nerve stimulator (64590).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93307 billed for date of service September 
28, 2022. 
 
You asked the Plan to pay for procedure code 93307. You say that this is procedure code is separately payable. 
The Plan denied your request. The Plan says payment for code 93307 is bundled into payment for code 93306. 
 
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 93307 is a column II code to column I code 93306 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 93307 billed for date of service September 28, 2022.