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

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on 
September 26, 2022. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the documentation does not 
support that the enrollee was inpatient status for this date of service. It is not appropriate to report inpatient 
evaluation and management service and place of service 21 (inpatient hospital) when the patient's claim history 
shows that the patient was in an outpatient hospital observation status for this date of service. The claim is not 
payable as billed. Based on this information, we decided that Medicare rules for coverage of the initial hospital 
care services have not been met. Therefore, we decided that the Plan does not have to pay for the initial 
hospital care services coded 99223 provided on September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 provided on August 31, 2022. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the billing of code 
G0483. 
 
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 G0483 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the medical record shows 
that only 20 drug classes were tested in this case. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0483 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code G0483 provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483) and 
injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or 
CT), lumbar or sacral, each additional level (64484). 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the injections are medically 
necessary due to spinal stenosis, lumbar region without neurogenic claudication. The Plan denied your request. 
The Plan says the criteria for a repeat ESI has not been met, the request cannot be approved. 
 
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 epidural steroid injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found according to the coverage criteria, a repeat ESI is indicated when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using same scale for at 
least three (3) months. If an enrollee fails to respond well to the initial ESI, a repeat ESI after 14 days can be 
performed, using a different approach, level and/or medication if appropriate, with the rationale and medical 
necessity for the second ESI documented in the medical record. In this case, the last TFESI was on January 30, 
2023, and provided 85% relief of pain for a duration much shorter than 3 months. The review has determined 
that the enrollee does not meet LCD criteria for the requested injections. The epidural injection is not medically 
necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with 
imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483) and injection(s), anesthetic 
agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, 
each additional level (64484).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan injection. 
 
You asked the Plan to pre-approve Hyalgan injection. You say that you have been on this medication for quite 
some time and is the only medication that relieves her symptoms with no side effects. The Plan denied your 
request. The Plan says because the requested injection serves the same purpose as the other injections available 
to you and this request is not considered medically reasonable or necessary. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Hyalgan injection. Our reviewer says 
that the criteria for coverage of this drug has not been met. Our physician reviewer found there is no 
documentation of trial and failure of Durolane, Euflexxa, Supartz, and GelSYN-3. The documentation also 
does not support that Durolane, Euflexxa, Supartz, and GelSYN- 3 would likely be less effective or would 
likely have adverse effects for you in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan injection (hyaluronic acid injection) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Hyalgan injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for July 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 submitted 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 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. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
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 submitted records 
do not support the billing of code 99223. Our reviewer found the enrollee presented to the emergency 
department (ED) for cardiac catheterization after an abnormal electrocardiogram (EKG). The evaluation and 
management code billed requires a comprehensive history, a comprehensive examination and medical decision making of high complexity. However, the medical records submitted did not support a comprehensive history 
and medical decision making of high complexity. The records do not support that there was a comprehensive 
history or medical decision making of high complexity. The records did support that there was a 
comprehensive 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99223 billed for July 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 72191 billed for date of service June 22, 
2022. 
 You asked the Plan to pay for procedure code(s) 72191. You say that the claim was billed correctly and should 
be paid. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 72191. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 72191. Based on this information, 
we decided that Medicare rules for coverage of procedure code 72191 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 72191 billed for date of service June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria 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 genicular nerve radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the review has determined that the genicular nerve 
radiofrequency ablations are considered experimental/investigational in nature. The requested genicular nerve 
radiofrequency ablation is not reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additions to lower extremities, pelvic control (L2624 x2) 
and combination, bilateral, lumbo-sacral, hip, femur orthosis (L1690) provided on August 30, 2022, and 
August 31, 2022. 
 
You asked the Plan to pay for the additions to lower extremities, pelvic control and combination, bilateral, 
lumbo-sacral, hip, femur orthosis. You say that the record clearly demonstrates the need for the product. The 
Plan denied your request. The Plan says the claim should not be paid as standard documentation requirements 
for all claims submitted for durable medical equipment were not met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
dates of service billed on the claim do not match the dates that the supplier shipped the item or the date of 
delivery that are shown in the documentation that was provided. Therefore, we decided that the Plan does not 
have to pay for the additions to lower extremities, pelvic control (L2624 x2) and combination, bilateral, lumbo-
sacral, hip, femur orthosis (L1690) provided on August 30, 2022, and August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on September 26, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the proof of 
delivery did not include an order number or details to corroborate the Delivery Ticket submitted. Of note, the 
proof of delivery is not itemized to indicate the specific supplies. 
 
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 argues that the proof of delivery did not include an order number or 
details to corroborate the delivery ticket submitted. However, the submitted documentation contains a itemized 
packing slip dated September 26, 2022, with the same tracking number as the delivery ticket dated September 
28, 2022. As such, the records show that the items in question were delivered, and the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the electrical stimulator supplies provided on 
September 26, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) 
vaccine and preventive counseling rendered on August 22, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that the enrollee had been injured or directly exposed to any illness related to the TDaP 
vaccine.  
 
Medicare rules say that providers must report services correctly. Providers must report services with the 
appropriate procedure code. 
 
We find that procedure code 99401 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code 99401 is non-covered. 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 tetanus, diphtheria, and acellular pertussis 
(TDaP) vaccine and preventive counseling rendered on August 22, 2022.  
 
Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
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 the enrollee currently meets LTACH 
admission criteria and waiting for a standard service decision may seriously jeopardize the life, health, or the 
ability to regain maximum function to the enrollee. The Plan denied your request. The Plan says the enrollee is 
receiving medically necessary acute and/or critical care and does not have clinical conditions that cannot be 
appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic 
advantage. 
 
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 appear to be presently stable for transfer given the ongoing 
tachycardia requiring intravenous diltiazem and is reported to not be stable for physical therapy treatments. 
 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99233 provided on March 9, 2022. 
 
You asked the Plan to pay for code 99233. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the medical records submitted 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 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 physician 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 the documentation 
supports the code billed. Our reviewer found while the provided record is poorly organized and labeled, it does 
indeed contain a detailed interval history. The documentation supports a detailed interval history and detailed 
examination. This means two of the three required components were supported in the documentation. 
Therefore, the health plans argument for denial is not supported. 
 
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 99233 have been met. Therefore, we decided that the Plan has to pay for 
code 99233 provided on March 9, 2022.  
 
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: 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. The Plan denied your request. The Plan says criteria for admission 
to the Acute Inpatient Rehabilitation setting have not been met, he enrollee's ongoing skilled therapy and 
nursing needs can be provided at a lower level of care, at a Skilled Nursing Facility, on an intermittent basis at 
home with home health care, or in a long-term care setting. 
 
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 does not require treatment by multiple therapies, including either 
physical or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and 
five days a week, or 15 hours over seven consecutive days. 
 
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.