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

 
We decided that the Plan does not have to pay for the elbow orthoses you billed for date of service January 5, 
2022. 
 
You asked the Plan to pay for the elbow orthoses. You say that you have provided medical records to support 
payment for these items. The Plan denied your request. The Plan says despite multiple requests, you have not 
provided proof of delivery of these items. 
 
The Plan must follow Medicare rules. Medicare rules say that suppliers must maintain proof of delivery 
documentation. Compliance with proof of delivery may be required as a condition of payment and must be 
made available as requested. In this case, you did provide a shipment receipt, but there is nothing in the 
documentation provided showing a packing slip or any information regarding what items were actually 
delivered related to this shipment receipt.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the elbow orthoses have not been met. Therefore, we decided that the Plan does not have to pay for 
the elbow orthoses you billed for date of service January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve acupuncture services. You say that the services are necessary. The Plan 
denied your request. The Plan says the records do not show you have a condition for which 
Acupuncture is covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the documentation received fails to indicate you have 
chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture services 
to be provided by an out-of-network provider.
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 acute 
care hospital where he/she is currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. 
 
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 waive the copayment for the injection(s), of an anesthetic agent(s) 
and/or steroid; transforaminal epidural, with imaging guidance (64483) provided on February 17, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copay for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay a $150 copayment for the Medicare-covered outpatient hospital facility visit 
provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the injection(s), of an anesthetic agent(s) and/or 
steroid; transforaminal epidural, with imaging guidance (64483) provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service September 
14, 2021. 
 
You asked the Plan to pay for procedure code 99233. You say that although the provider who billed this 
particular service and the other provider who billed an evaluation and management (E/M) code on this date of 
service are in the same practice, they are different specialties.  Therefore, separate payment should be made. 
The Plan denied your request. The Plan says two providers in the same group cannot bell for E/M services on 
the same day. 
 
The Plan must follow Medicare rules. Medicare rules say that physicians in the same group practice who are in 
the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician 
or more than one physician in the same specialty in the same group, only one evaluation and management 
service may be reported unless the evaluation and management services are for unrelated problems. Physicians 
in the same group practice but who are in different specialties may bill and be paid without regard to their 
membership in the same group. 
 
We looked at the file and Medicare rules. There were two E/M services provided by providers in the same 
group on this date of service.  According to Medicare rules, two separate E/M visits would only be payable if 
the providers were in different specialties or if the member was seen for different reasons.  Although you 
argued that these two providers are of different specialties, that is not reflected in Medicare's National Plan and 
Provider Enumeration System (NPPES) National Provider Identifier (NPI) records.  The Medicare NPPES NPI 
Registry lists both providers who billed the E/M codes on this date of service as having a specialty of Internal 
Medicine. In addition, both providers billed with a diagnosis of F1190, indicating that the patient has seen for 
the same condition by both providers. 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 date of service September 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography services billed with codes 93312, 93320, 
and 93325 for date of service April 8, 2021. 
 
You asked the Plan to pay for the echocardiography services. You say that these codes should be paid. The 
Plan denied your request. The Plan says these codes are not supported by the medical record. 
 
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 93312 is Echocardiography, transesophageal, real-time 
with image documentation (2D) (with or without M-mode recording); including probe placement, image 
acquisition, interpretation and report. The CPT Code Manual definition of code 93320 is Doppler 
echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to 
codes for echocardiographic imaging); complete. The CPT Code Manual definition of code 93325 is Doppler 
echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography). 
  
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 echocardiography services. Our reviewer says that codes 
93312, 93320, and 93325 are not supported by the medical record. Our reviewer found for code 93312, the 
procedure report does not include details of a the transesophageal echocardiogram (TEE) procedure, per 
Medicare guidelines.  The procedure report documents "TEE Placement *OGT inserted and stomach suctioned 
prior to TEE probe insertion, TEE probe lubricated and placed atramatically, TEE Placement Attempts: 1".  For 
codes 93320 and 93325, because the TEE cannot be verified, these codes would not be covered. 
 
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 echocardiography services have not been met. Therefore, we decided that 
the Plan does not have to pay for echocardiography services billed with codes 93312, 93320, and 93325 for 
date of service April 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, 
anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle 
or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging 
guidance (CPT code 62322). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says that the Medicare rules have not been 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 the service. Our physician reviewer 
found with addendum the enrollee meets the LCD criteria. The request is deemed medically reasonable and 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, 
other solution), not including neurolytic substances, including needle or catheter placement, interlaminar 
epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance (CPT code 62322).  
 
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 procedure codes 64483, 64484, J1100, and Q9966 billed for 
date of service July 30, 2021. 
 
You asked the Plan to pay for procedure codes 64483, 64484, J1100, and Q9966. You say that these services 
should be paid. The Plan denied your request. The Plan says the medical records do not support the services 
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 64483 is injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level. The CPT 
Code Manual definition of code 64484 is injection(s), anesthetic agent(s) and/or steroid; transforaminal 
epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in 
addition to code for primary procedure). The CPT Code Manual definition of code J1100 is injection, 
dexamethasone sodium phosphate, 1 mg. The CPT Code Manual definition of code Q9966 is low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml. 
 
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 codes 64483, 64484, J1100, and Q9966. Our 
reviewer says that codes 64483, 64484, J1100, and Q9966 are not supported in the medical record. Our 
reviewer found for code 64483, the procedure report documents bilateral lumbar root block injection block 
under fluoroscopic guidance; The identical procedure was repeated at L5 level".  For code 64484, this 
procedure was not documented in the report.  For code J1100, the procedure report describes a compound drug 
was administered and documents "a total of volume of 2 cc Bupivacaine plan MPF 0.25% with Dexamethasone 
8 mg was injected".  Therefore, this procedure code cannot be verified. For code Q9966, the procedure report 
does not document low osmolar contrast material, so this procedure cannot be verified. 
 
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 codes 64483, 64484, J1100, and Q9966 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 64483, 64484, J1100, and Q9966 
billed for date of service July 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95385 billed for date of service April 12, 
2021. 
 
You asked the Plan to pay for procedure code 45385. You say that this service should be billed. The Plan 
denied your request. The Plan says the records do not support payment of this code. 
 
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 45385 is colonoscopy, flexible; with removal of tumor(s), 
polyp(s), or other lesion(s) by snare technique. 
 
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 45385. Our reviewer says that this procedure 
code is not supported in the medical record. Our reviewer found the procedure report does not include 
documentation to support that tumor, polyp or other lesions were removed and a biopsy taken was at different sites of the colon.  In this case, modifier -59 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 procedure code 45385 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95385 billed for date of service April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a pacemaker for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show non-reversible symptomatic bradycardia due to either 
sinus node dysfunction or second degree and/or third degree atrioventricular block. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while the enrollee has a history of right bundle branch block (RBBB) and syncope, there is no 
documentation of symptomatic bradycardia. As such, there is insufficient documentation to support the medical 
necessity for insertion of a pacemaker in 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a pacemaker for the enrollee.
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be 
clinically advantageous. Transfer may be considered when treatment has completed. 
 
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: 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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program.  
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 two units of procedure code 99292-25 billed for date of 
service September 27, 2021. 
 
You asked the Plan to pay for two units of code 99292-25. You say that this code should be paid. The Plan 
denied your request. The Plan says this code is not supported by the medical record. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
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 two units of code 99292-25. Our reviewer says that this code 
is not supported in the medical record. Our reviewer found the medical record documents 80 minutes of critical care given.  In this case, CPT 99291 covers the first 74 minutes.  An additional 7 minutes would be coded CPT 
99292 for 1 unit of service.  The total time should be 75 - 104 minutes = 99291 x 1 and 99292 x 1.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two units of code 99292-25 have not been met. Therefore, we decided that the 
Plan does not have to pay for two units of procedure code 99292-25 billed for date of service September 27, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93312-26-59 billed for date of service 
December 16, 2021. 
 
You asked the Plan to pay for procedure code 93312-26-59. You say that this service should be paid. The Plan 
denied your request. The Plan says the record does not support this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93312 is echocardiography, transesophageal, real-time 
with image documentation (2D) (with or without M-mode recording); including probe placement, image 
acquisition, interpretation and report 
 
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 93312-26-59. Our reviewer says that 
procedure code 93312-26-59 is not supported in the medical record. Our reviewer found the anesthesia report does not document this procedure was performed as diagnostic and it does not meet coding requirements for 
transesophageal echocardiography procedures.  
 
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 93312-26-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93312-26-59 billed for date of service December 16, 2021.