Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78452 billed for date of service January 29, 
2022. 
 
You asked the Plan to pay for procedure code 78452. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 78452 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 78452 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 78452 billed for date of service January 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250). 
 
You asked the Plan to pre-approve a chest CT scan. You say that the requested service is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 chest CT scan. Our reviewer says that 
the requested service is not medically reasonable and necessary in this case. Our physician reviewer found that 
the nature of the enrollee's history of "lung mass" is not detailed in the records submitted. The last CT chest 
report (of December 10, 2021) revealed post-operative changes in the right upper lobe and no nodules or other 
findings besides emphysematous disease. The order says the request is for an annual CT exam, but there are no 
details as to the reason for the need for annual follow-up. 
 
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 chest CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a CT scan of the chest (71250).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493 x 2, 64494 x 2). 
 
You asked the Plan to pre-approve the injections. You say that you are still having a lot of pain. You say that 
you are off of your pain medication. You also say that you just need some pain relief. The Plan denied your 
request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all the criteria. 
 
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 injections. Our reviewer says that 
the requested facet joint injections are not medically necessary. Our physician reviewer found there is no 
documentation of the pain relief obtained or the duration of pain relief from the previous facet joint injections. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
your pain, including, but not limited to, fracture, tumor, infection, or significant deformity. Therefore, the 
reviewer found that the requested facet joint injections are not 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64493 x 2, 64494 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on April 4, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says original 
Medicare does not cover routine eye exams (eye refractions) for eyeglasses/contacts. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Medicare does not cover refractive procedures even 
when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we 
decided that the Plan does not have to pay for an eye refraction provided on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service March 19, 
2022. 
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99232 is bundled into payment for 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, we have confirmed that code 99232 
is a column II code to column I code 99223. 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 99232 billed for date of service March 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided January 1, 2022, to 
January 30, 2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim is not payable as submitted. 
 
The Plan follows Medicare rules. The rules say that the claim and NOA must be submitted with correct 
information to be processed. 
 
Review of the file shows that the admission date on the claim is January 6, 2022; however, the admission date 
on the NOA is January 1, 2022. As these dates do not match, no payment can be made on this claim. Therefore, 
we decided that the Plan does not have to pay for the home health services provided January 1, 2022, to 
January 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from December 29, 2020, to December 31, 2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance 
Prospective Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the case file does not contain 
physician documentation that the enrollee in this case had a urinary tract infection during the dates at issue. 
Additionally, the case file does not contain physician documentation that the enrollee in this case required 
isolation for active infectious disease during the dates at issue. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from December 29, 2020, to 
December 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. 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 viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary 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 Orthovisc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed at least three (3) months of conservative therapy, including non-pharmacologic therapy, analgesics, non-
steroidal anti-inflammatory drugs (NSAIDs), and cortisone injections. The review has determined that the 
enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transport mileage. 
 
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 request exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 36 one-way trips each year and each one-way trip must not exceed 50 miles of 
driving distance.  
 We looked at your request, the records in the case file, and the rules. The file shows that you are requesting a 
one-way trip for 56 miles. This exceeds the 50 mile limit per one-way trip. Based on this information, we 
decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional routine transport mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided April 21, 
2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that attached is the operative report or 
documents which details the services and provides proof of necessity. The Plan denied your request. The Plan 
says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) provided April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Monovisc (J7237) injection. 
 
You asked the Plan to pre-approve Monovisc. You say that the enrollee needs this. The Plan denied your 
request. The Plan says the requested drug is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when all 
the 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 Monovisc. Our reviewer says that the 
requested Monovisc injection is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate osteoarthritis as opposed to isolated stable osteochondritis dissicans lesions. 
Therefore, the reviewer found that that the requested Monovisc injection is not medically necessary in this 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Monovisc (J7237) injection.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound screening procedure provided on April 27, 
2022. 
 
You asked the Plan to pay for the screening ultrasound. You say that this was correctly billed for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee does not meet criteria for this screening. 
 
The Plan must follow Medicare rules. Medicare rules say that AAA screening is covered only when the 
enrollee meets the criteria listed in the Medicare rules section. 
 
We looked at the file and Medicare rules. No medical records were submitted other than the imaging report. 
Though it is noted that the enrollee is a former smoker, he is not between 65 and 75 years of age. There is no 
reported family history of AAA, and there have been no qualifying new risk factors published through a 
national coverage determination. Based on this information, we decided that Medicare rules for coverage of the 
screening ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the 
ultrasound screening procedure provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided March 21, 2022. 
 You asked the Plan to pay for the pneumatic compression device and appliance. You say that you are not 
contracted with the facility and are not notified that your product has been issued to the enrollee. The Plan 
denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep 
vein thrombosis during and/or following surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that a PCD that provides 
intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a 
preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not 
eligible for reimbursement. 
 
In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service 
would have been included under the facility claim. Payment for this service is the responsibility of the facility 
or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of 
the pneumatic compression device and appliance have not been met. Therefore, we decided that the Plan does 
not have to pay for the pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) 
provided March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve under pads and diapers. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requested items are not covered by Medicare or the health plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve under pads and diapers.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a monoclonal antibody injection provided to the enrollee on July 20, 
2022. 
 
You asked the Plan to pay for the injection. You say that this should be paid for. The Plan denied your request. 
The Plan says that the ambulance benefit is a transport benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan did not forward a valid denial in this case. The services were not really 
done in an ambulance setting, so the ambulance - no transport rules don't really apply here. The records show 
that this was a Mobile Integrated Health (MIH) visit at a doctor's office/clinic - this was not a situation where 
an ambulance responded to a situation for an emergency, and then didn't transport the enrollee. Therefore, we 
decided that the Plan has to pay for a monoclonal antibody injection provided to the enrollee on July 20, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation services rendered on March 11, 
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 99442 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 99442 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 11-20 minutes of medical discussion. 
 
We find that CPT code 99442 is not supported in the medical record. Specifically, the file shows that 
evaluation and management code 99215 (office visit) was billed within seven days of code 99442. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the telephone evaluation services rendered on March 11, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back-up battery for a continuous positive airway 
pressure (CPAP) device. 
 
You asked the Plan to pre-approve a back-up CPAP battery. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for durable medical 
equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a back-up battery for a CPAP device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 16, 2022, to 
April 18, 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 
medical records support the billing of principal diagnosis code A41.9 with DRG 871. The Plan denied your 
request. The Plan says the medical records do not support the billing of principal diagnosis code A41.9 with 
DRG 871. 
 
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 A41.9. 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 the medical records do not support the billing of principal diagnosis code A41.9 with DRG 871. Our 
physician reviewer found the reviewed documentation indicates that the enrollee presented to the emergency 
department (ED) on April 16, 2022, with a chief complaint of malaise, fatigue, and cough. Tachycardia and 
fever were documented. Though a diagnosis of sepsis was noted during the stay, laboratory data reflected the 
enrollee was without clear signs of systemic response. There did not appear to be evidence of significant 
thrombocytopenia, leukocytosis, hepatic, or renal dysfunction. Lactic acid was 1.3. The enrollee remained alert 
and oriented throughout admission. Skin was warm and dry. No documentation of persistent hypotension, 
hypoxia, or urine output less than 500 ml/day. In this case there was no clinical or laboratory evidence of 
sepsis. The review has determined that the medical records do not support the billing of principal diagnosis 
code A41.9 (Sepsis, unspecified organism) with DRG 871.  
 
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 April 16, 2022, to April 18, 2022, at the Diagnosis Related Group 
(DRG) originally billed.