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

 
We decided that the Plan does not have to pay for the critical care service (99291) provided on March 14, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is included in the global surgery package. 
 
The Plan follows Medicare rules. The rules say that The Medicare Fee Schedule Data Base (MFSDB) provides 
the postoperative periods that apply to each surgical procedure. If there is an indicator of 000, postoperative 
visits beyond the day of the procedure are not included in the payment amount for the surgery.  
 
This is a minor procedure that has a global surgery period of 00 days. The initial evaluation (code 99291), is 
included when billed the same day as minor surgery procedure (code 27250), without an appropriate modifier. 
Therefore, we decided that the Plan does not have to pay for the critical care service (99291) provided on 
March 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 9, 2022, 
through December 8, 2022. 
 
You asked the Plan to pay for the home health services. You say that this claim was billed in accordance with 
the billing guidelines. The Plan denied your request. The Plan says this claim has an invalid FIPS code 
reported. 
 
The Plan must follow Medicare rules. Medicare rules say that HHAs must report value code 85 to report the 
Federal Information Processing Standards (FIPS) state and county code of where the services were received.  
 
 We looked at the file and Medicare rules. The number listed in value code 85 on this claim is not a valid FIPS 
code for the county in which these services were performed. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from November 9, 2022, through December 8, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you are diagnosed with acute 
hypoxemia respiratory failure, interstitial lung disease and require 24/7 oxygen therapy. The standard portable 
oxygen system, the oxygen home fill system with portable D-cylinder gaseous tanks provided to you only meet 
your medical need at home. This does not adequately meet your medical need outside your home. The Plan 
denied your request. The Plan says portable oxygen concentrators are an exception to the standard and require 
documentation to support the exception such as attempted and failure of the standard item to meet your needs. 
 
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 portable oxygen concentrator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found provided records in this case do not document that your present portable D-
cylinder gaseous tanks are inadequate for your portability needs. As stated in the Local Coverage Article: 
Standard Documentation Requirements for All Claims Submitted to DME MACs - A55426: Supplier-
produced records, even if signed by the treating practitioner, and attestation letters (e.g., letters of medical 
necessity) are deemed not to be part of a medical record for Medicare payment purposes. Templates and forms, 
including CMS CMNs, are subject to corroboration with information in the medical record. A prescription is 
not considered to be part of the medical record. Medical information intended to demonstrate compliance with 
coverage criteria may be included on the prescription but must be corroborated by information contained in the 
medical record. The enrollee's medical record must contain sufficient documentation of the enrollee's medical 
condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or 
replacement. The information should include the enrollee's diagnosis and other pertinent information including, 
but not limited to, duration of the enrollee's condition, clinical course (worsening or improvement), prognosis, 
nature and extent of functional limitations, other therapeutic interventions and results, past experience with 
related items, etc. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 27, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. 
 The Plan denied your request. The Plan says equipment used in a facility for a procedure is not separately 
payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical procedure coded with procedure codes 37243, 
36247, 36245, 76937 and 99152 provided on March 3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical procedure. You say that although you understand you are out of 
network, you provided emergent services to the enrollee in good faith and is asking for overturn of the denial. 
The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 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 the surgical procedure coded with procedure codes 
37243, 36247, 36245, 76937 and 99152 provided on March 3, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexcom G7 CGM. The Plan denied your request. The Plan says a CGM is 
not covered when the enrollee is not on insulin. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a Dexcom G7 CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on June 26, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223. The Plan denied your request. The Plan says the medical 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 procedure code 99223. Our reviewer says that the medical 
records do not support the billing of code 99223. Our reviewer found the review has determined that the 
medical records supported a comprehensive history and a comprehensive examination but did not support 
medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on June 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic colonography (CTC). 
 
You asked the Plan to pre-approve the CTC. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says CTC screenings for colon cancer are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a screening computed tomographic colonography 
(CTC) is nationally non-covered by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CTC have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
computed tomographic colonography (CTC).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a leadless pacemaker (33274). 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers leadless pacemakers when 
procedures are performed in FDA-approved studies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a leadless pacemaker have not been met. Specifically, there is no indication evident in the case 
record that the enrollee is participating in an FDA-approve study. Therefore, we decided that the Plan does not 
have to pre-approve placement of a leadless pacemaker (33274).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this is needed to help you breathe and keep fluid out 
of your lungs. The Plan denied your request. The Plan says a ventilator is not covered by Medicare for this 
purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy  regardless of the underlying medical condition  shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285, 99053) provided on May 
30, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed codes. 
 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 99285 is emergency department evaluation and 
management requiring a comprehensive history, a comprehensive examination, and medical decision making 
of high complexity. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the emergency room services. Our reviewer says that the 
codes billed are not supported by the records provided. Our reviewer found there was insufficient 
documentation to describe a comprehensive history or physical. Code 99053 has a status of "B" per the 
National Physician Fee Schedule and is bundled for payment with another service. 
 
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 emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services (99285, 99053) provided on May 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 18, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this claim was filed timely. The Plan denied 
your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until December 13, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on March 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided by a Licensed 
Mental Health Counselor (LMHC) on November 8, 2022. 
 
You asked the Plan to pay for the LMHC services. You say that this is a valid service and previous visits with 
this provider were paid. The Plan denied your request. The Plan says services by a LMHC are not covered by 
Medicare. The Plan says that although previous claims were paid, they were paid in error. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists. The provider that you 
saw is a LMHC, which is not a valid provider type for Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LMHC services have not been met. Therefore, we decided that the Plan does not have to pay 
for outpatient mental health services provided by a Licensed Mental Health Counselor (LMHC) on November 
8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27335 billed for date of service September 1, 
2022. 
 You asked the Plan to pay for procedure code 27335. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 27335 is bundled into payment for code 27447. 
 
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 27335 
is a column II code to column I code 27447. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 27335 billed for date of service September 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 You asked the Plan to pre-approve Synvisc. You say that Synvisc is medically necessary. The Plan denied your 
request. The Plan says a trial of Orthovisc, Hyalgan, and Supartz is required before alternatives can be 
considered. 
 
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 Synvisc. Our reviewer says that 
Synvisc is not medically necessary. Our physician reviewer found the records do not show a trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for November 23, 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 procedure code 99285 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for these services. Our reviewer says that procedure code 99285 
is not supported. Our reviewer found the submitted records do not document that there was a comprehensive history, comprehensive examination, and medical decision making of high complexity. Code 99285 is therefore 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99285 billed for November 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), a segmental 
pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental pneumatic appliance 
for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you disagree 
with the adverse determination and ask you do an additional review with the information included. The Plan 
denied your request. The Plan says the request is not medically necessary because the enrollee does not have 
swelling of her chest, trunk, or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652), a segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home, or custodial care visit provided on 
November 28, 2022. 
 
You asked the Plan to pay for the domiciliary, rest home, or custodial care visit. The Plan denied your request. 
The Plan says 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 Plan says that the Plan has also determined that these 
services are not urgent or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home, or custodial care visit provided on 
November 28, 2022.