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

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99233 billed for dates of service 
October 20, 2022, to October 22, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed 
services 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 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.  
 The definition of CPT 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. 
 
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 pay for the billed services. Our reviewer found that 
the enrollee presented to the emergency room with abdominal pain, nausea, and vomiting. He was admitted for 
retrocecal appendicitis. Code 99223 was not supported. This code requires a comprehensive history, a 
comprehensive examination and medical decision making of high complexity. In this case, the medical records 
submitted did not support a medical decision making of high complexity. Code 99233 was not supported. This 
code requires two out of these three key components: a detailed interval history, a detailed examination and 
medical decision making of high complexity. In this case, the medical records submitted did not support a 
detailed interval history and medical decision making of high complexity. 
 
We looked at this physicians review, the file, and Medicare rules. 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 codes 99223 and 99233 billed for dates of service October 20, 2022, to October 
22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on October 3, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for outpatient surgery. You say that you believe this was medically necessary. The 
Plan denied your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient surgery provided on October 3, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rental charge for a transcutaneous electrical nerve 
stimulator (TENS) unit for the month beginning on September 22, 2022. 
 
You asked the Plan to pay for the TENS rental charge. You say that the services were medically necessary and 
ordered by the treating provider. The Plan denied your request. The Plan says the documentation submitted did 
not include a valid Proof of Delivery, or a Delivery Ticket. 
 
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 or relevant medical records which support medical 
necessity for the supplies provided in this case. The proof of delivery submitted does not indicate what delivery 
service was used. As such, it cannot be confirmed that it is legitimate. In addition, no progress note from 
around the date in which the order was signed is included in the file. The notes that are included do not make 
any mention that the enrollee has been prescribed or is using a TENS unit. The notes indicate that only 
medications are being used to treat her pain. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
rental charge for a transcutaneous electrical nerve stimulator (TENS) unit for the month beginning on 
September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87481, 87500, 87640, 
87652, 87653, 87798, 87798-91 provided May 31, 2022. 
 You asked the Plan to pay for the laboratory services. You say that test was ordered based upon the treating 
physicians clinical training and medical necessity. The Plan denied your request. The Plan says that the entity 
or provider cannot be located. 
 
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 pay for the laboratory 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 the requested laboratory studies are not superior to other standard 
treatments of medical conditions. Additionally, there are no medical records that indicate the laboratory studies 
are medically necessary. There is no medical documentation available for review that supports the prescribed 
testing. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 87481, 87500, 87640, 87652, 87653, 87798, 87798-91 
provided May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that you are appealing the denied 
CGM because it is medically necessary for the enrollee. The Plan denied your request. The Plan says the 
Medicare criteria was not met. 
  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 CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM) and related supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral device (E0486NU). 
 
You asked the Plan to pre-approve an oral device. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the request is not reasonable or medically necessary as you have been 
issued a continuous positive airway pressure machine and no mention of you not tolerating the continuous 
positive airway pressure machine or the device not being operable or repairable. The Plan states the request has 
been denied as the LCD criteria 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 an oral device. Our physician reviewer 
found there is no documentation of a clinical visit prior to ordering the oral device. This is a Medicare 
requirement. There is no indication that you were having difficulty tolerating continuous positive airway 
pressure (CPAP). There is no documentation of attempts to repair or replace the CPAP device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oral device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an oral device (E0486NU).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case. 
Our physician reviewer found in this case, the previous C7-T1 ESI performed on November 28, 2022, provided 
75% relief of pain, which had worn off by February 21, 2023. The review has determined that the requested 
epidural steroid injection does not meet the Medicare LCD coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81479) provided on September 8, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
covered by Medicare. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81479) 
provided on September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says your request is not medically necessary because pulmonary function 
test report (PFT), and an overnight sleep oximetry were not received. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician reviewer found there is no diagnosis of chronic obstructive pulmonary disease (COPD), thoracic restrictive 
disease, or neuromuscular disease. The appropriate treatment for obesity hypoventilation syndrome is 
continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP). Medicare does not 
cover a home ventilator for the treatment of obesity hypoventilation syndrome, or when used at settings that 
can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
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 December 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement that indicates that these tests are included in the dialysis rate. 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 
December 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99222 billed for date of service October 13, 2022. 
 
You asked the Plan to pay for code 99222. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says that code 99222 is not supported by the medical record because there 
is no comprehensive history. 
 
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 99222 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 moderate 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 99222. Our reviewer says that code 99222 is supported 
by the medical record. Our reviewer found the enrollee was a then, 65 year old female who presented to the 
emergency room with complaints of weakness. Earlier that night she states she was walking out of her bedroom 
when she felt light headed and weak. She said she fell against the door and then the floor. While being 
evaluated, she reported blood coming from her umbilicus. The enrollee has a known history of recurrent 
granulosa cell tumor.  She was being followed with gynecologic oncology. The enrollee stated that she woke 
up and noted "a pool of blood" on her sheets. In this case, the medical records submitted did support a 
comprehensive history and medical decision making of moderate 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 99222 have been met. Therefore, we decided that the Plan has to pay for 
code 99222 billed for date of service October 13, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you 70% of the billed charges for psychotherapy provided 
on September 29, 2022, by an out-of-network provider. 
 
You asked the Plan to reimburse you 70% of the billed charges for the psychotherapy. You say that you should 
have been reimbursed 70% of the billed charges. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. You were reimbursed correctly based on the allowable charges minus your 30% 
coinsurance. 
 
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 30% 
coinsurance for physician/practitioner services, including doctors office visits.  
 You have been asked to pay a 30% coinsurance for the psychotherapy. This service falls within the 
physician/practitioner services, including doctors office visits benefit category. 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 reimburse you 70% of the billed charges for psychotherapy provided on September 29, 2022, by an 
out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left atrial appendage closure device (LAAC).  
You asked the Plan to pre-approve a LAAC. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC devices are covered when specific 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 LAAC. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found as such, guidelines would not support 
implantation of a LAAC in this setting. In summary, LAAC placement would not be considered reasonable or 
medically necessary in this enrollees 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 LAAC have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a left atrial appendage closure device (LAAC).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services (99490 and 99439) 
provided on May 12, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records provided. 
 
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 99490 is the chronic care management services with the 
following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or 
until the death of the patient, chronic conditions that place the patient at significant risk of death, acute 
exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, 
revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health 
care professional, per calendar month. The definition of code 99439 is the chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 
months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, 
acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, 
revised, or monitored; each additional 20 minutes of clinical staff time directed by a physician or other 
qualified health care professional, per calendar month (List separately in addition to code for primary 
procedure) 
 
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 found the review has determined 
that the documentation did not support procedure code 99490 provided on May 12, 2022. The documentation 
did not support procedure code 99439 provided on May 12, 2022. 
 
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 chronic care management services (99490 and 99439) provided on May 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee arthroplasty procedure (27447). 
 
You asked the Plan to pre-approve a knee arthroplasty. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 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 knee arthroplasty. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no recent 6-week trial of physical therapy (PT) for knee pain. More trials of 
conservative measures are needed to demonstrate the medical need for the requested services. 
 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 knee arthroplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee arthroplasty procedure (27447).