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

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service February 22, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. The Plan denied your request. The Plan says payment for 
code 0245U is bundled into payment for code 0018U. 
 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 0245U 
is a column II code to column I code 0018U. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 0245U billed for date of service February 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that facet injections 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic back and neck 
pain. There is documented radiculopathy. The records do not support that the criteria for coverage of the requested facet injections are met. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99214) provided on June 21, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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 99214 is not supported in the medical record. Specifically, the claim was billed with a 
primary diagnosis code of F06.31. This code is not a valid primary diagnosis code. The underlying diagnosis 
must be coded first. Based on this information, we decided that Medicare rules for coverage of the physician 
services have not been met. Therefore, we decided that the Plan does not have to pay for physician services 
(99214) provided on June 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 18, 2022, to 
May 24, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says the documentation 
does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code N17.0, described as acute 
kidney failure with tubular necrosis. 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed code. Our physician reviewer found that the patient is an 80-year-old female who was treated in the 
hospital with a mitral valve replacement. Kidney function worsened and improved again after switching from 
bumetanide for furosemide as the diuretic medication. Although clinically this could be tubular necrosis, there 
was no objective testing to confirm this was a diagnosis such as via urine testing. Therefore, acute kidney 
failure with tubular necrosis, which would need to be confirmed with objective testing results listed above, will 
be considered not medically necessary or appropriate for this admission based on the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 18, 2022, to May 24, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 24, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 70450 billed for date of service October 24, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services (procedure code 99223) provided to the 
enrollee on September 11, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported properly. 
 
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." 
 
CPT 99223 is not recognized when billed as outpatient. An outpatient claim was also billed on the same day. 
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 inpatient services (procedure code 99223) 
provided to the enrollee on September 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace provided on October 11, 2022. 
 
You asked the Plan to pay for the back brace. The Plan denied your request. The Plan says the records do not 
support the back brace. 
 
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 documentation does not contain relevant medical records which support medical necessity for the back 
brace provided in this case. The supplied records do not show that the enrollee was see within the previous six 
months. The records also do not indicate a diagnosis that would necessitate a back brace. 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 back brace provided on October 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiomyopathy screen panel (81439) 
provided September 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the provider who referred this test did 
believe this was a necessary test to render on the enrollee, and therefore, should be covered and re-evaluated. The Plan denied your request. The Plan says procedure code 81439 has met the associated deny relationship 
criteria. 
 
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 the review indicates that the enrollee has a history of hypertension, hyperlipidemia, 
chronic obstructive pulmonary disease, gastroesophageal reflux disease, and bilateral knee degenerative joint 
disease. There is no specific clinical rationale for the requested lab studies. Given the documentation provided 
for reviewed, the items/services at issue in this case are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the hereditary cardiomyopathy screen panel (81439) provided September 8, 2021.
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. You say that the enrollee would benefit from rehabilitation 
services. The Plan denied your request. The Plan says records show that there is no need for an intensive 
rehabilitation program. 
 
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 medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of care. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 10, 2022. 
 
You asked the Plan to pay for the office visit. You say that you were involved in a very minor car accident with 
no other party involved, and this visit was a follow-up to the accident. The Plan denied your request. The Plan 
says review of the information determined that the office visit was scheduled for completion of administrative 
paperwork from the Department of Motor Vehicles (DMV), which is not covered under your medical Plan. 
 
The Plan contract says that services considered not reasonable and necessary, according to the standards of 
Original Medicare are not covered under any condition. 
 
We looked at the file and the Plans rules. Based on this information, we decided that the Plans rules for 
coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
office visit provided on October 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval. 
 
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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found provided records document a 
diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records 
document that the home ventilator is being requested for use in average volume assured pressure support 
(AVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-
up rate. As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide 
CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (80307, G0480) provided on September 25, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you disagree with the denial and are requesting 
reconsideration for payment on this claim. The Plan denied your request. The Plan says Medicare rules say that 
health plans can require enrollees to get care from network providers. The Plan also says they pay for care for 
out-of-network providers only in cases involving emergencies, out of area urgent care, and pre-approved care. 
The requested provider is not a network provider with the Plan. 
 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 drug testing (80307, G0480) provided on 
September 25, 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 continuous glucose monitor supplies (K0553) provided 
on September 28, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the coverage criteria 
are not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the supplies. Our reviewer says that the 
requested supplies are not medically reasonable and necessary in this case. Our physician reviewer found that 
the last office note from August says that the enrollee no longer uses Novolog, hence the enrollee is on one shot 
of insulin/d, and the coverage criteria are not met. 
 
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 supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for the continuous glucose monitor supplies (K0553) provided on September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation, single facet joint (64635 
x 2), and each additional facet joint (64636 x 2). 
 
You asked the Plan to pre-approve repeat RFA. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat thermal facet joint RFA at the same anatomic 
site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six months or at least 50% consistent improvement in the ability to perform 
previously painful movements and ADLs as compared to baseline measurement using the same scale. 
 
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 repeat RFA. Our reviewer says that the 
requested repeat RFA are not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that the enrollee had 50% pain relief for at least six months. Therefore, the reviewer found 
that the requested repeat RFA are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat radiofrequency ablation, single facet joint (64635 x 2), and each additional facet 
joint (64636 x 2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 99223. You say that these services were rendered by different 
providers with different specialties. The Plan denied your request. The Plan says payment for code 99223 is 
bundled into payment for code 31500. 
 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 99223 
is a column II code to column I code 31500. Both of these services were performed by providers with a primary 
taxonomy/specialty of 207P00000X - Emergency Medicine. This claim has not been billed with an appropriate 
modifier to bypass the edit. 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 99223 billed for date of service 
April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV), group 1 standard, 
patient weight capacity up to and including 300 pounds (K0800) and an oxygen tank holder. 
 
You asked the Plan to pre-approve a POV and an oxygen tank holder. You say that the enrollee is not able to 
maneuver a manual wheelchair and cannot walk more than a couple feet as he is on oxygen 24 hours a day. The 
enrollee's pulmonary issues are the reason for his mobility limitations. The enrollee does not receive physical 
therapy (PT) services or occupational therapy (OT) services. He has been referred to neurology and has an 
upcoming appointment for a shake he has had. The enrollee should have some independence in his last years of 
life which the mobility scooter would give him. The Plan denied your request. The Plan says the request does 
not meet criteria for the scooter and the oxygen tank holder for the scooter, as the enrollee could use a walker 
with a seat or a manual wheelchair. The Plan also says notes indicate that the purpose of the scooter is for use 
in the community. 
 
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 POV and an oxygen tank holder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not support that the enrollee has a mobility 
limitation that significantly impairs his ability to participate in one or more mobility-related activities of daily 
living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the 
home. The documentation does not support that the enrollee's mobility limitation cannot be sufficiently 
resolved by the use of an appropriately fitted walker or that the enrollee's home provides adequate access 
between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is requested. The 
documentation does not support that the use of a manual wheelchair will significantly improve the enrollee's 
ability to participate in MRADLs and that he will use it on a regular basis in the home. 
 
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 POV and an oxygen tank holder have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power operated vehicle (POV), group 1 standard, patient weight 
capacity up to and including 300 pounds (K0800) and an oxygen tank holder.