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

 
We decided that the Plan does not have to pay for code 99285 billed for date of service July 6, 2022. 
 
You asked the Plan to pay for code 99285. You say that this service was medically necessary and appropriate, 
and this code should be paid. The Plan denied your request. The Plan says code 99285 is not supported because 
the medical records do not document decision making of high complexity. 
 
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 these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
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 99285. Our reviewer says that the billing of code 99285 
is not supported in the medical records. Our reviewer found the enrollee was a then, 38-year-old female with a 
history of cirrhosis, systemic lupus erythematosus, rheumatoid arthritis, and status post cholecystectomy who 
presented to the emergency room on July 6, 2022, with right upper and lower quadrant abdominal pain. She 
was evaluated with a history and physical exam, laboratory studies and a CT scan of the abdomen. Current 
Procedural Terminology (CPT) code 99285 (1 unit) was not supported. This emergency department evaluation 
and management 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 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 code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service July 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the brain. 
 
You asked the Plan to pre-approve the CT scan. You say that you are having migraine headaches. The Plan 
denied your request. The Plan says there was no clinical information to support a repeated CT of the brain. 
 
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 the CT scan. Our reviewer says that the 
CT scan of the brain is not medically necessary. Our physician reviewer found that the enrollee has migraine 
headaches. A CT of the head was requested. However, classic migraine headaches do not warrant advanced 
imaging according to current guidelines and are diagnosed by clinical history and a negative physical exam. 
Also, a recent CT of the brain from November 18, 2022, was performed without significant abnormality. The 
provided documentation was limited and did not clearly show any other history or findings on examination that 
would suggest another cause of their headaches such as a red flag diagnosis or of a change in symptoms since 
the prior imaging to justify repeat advanced imaging. 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the brain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve buildup for crown (D2950) Tooth #3 and 5, replacement 
tooth in a bridge (D6240) Tooth #4, retainer for a bridge (D6750) Tooth #3 and 5 and surgical removal of 
residual root (D7250) Tooth #4, 12 and 13. 
 
You asked the Plan to pre-approve dental services. You say that you your teeth have broken away due to decay 
and only roots remain. This is why there is no documentation of incomplete removal by another provider. The 
roots need to be removed in order to replace the teeth with a b ridge or partial denture. The Plan denied your 
request. The Plan says the requested services do not meet the criteria that requires that the root fragments 
remaining are a result of roots left behind by another provider. The Plan denied because there is no 
documentation of another provider attempting to extract the tooth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
services when the services are medically necessary and reasonable.  
 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 dental services. Our physician reviewer 
found the codes provided under D7250 would not be correct as the teeth in question do not appear to have been 
the result of previously attempted extractions. A surgical extraction code may be used if a standard forceps 
removal is not possible for these teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve surgical removal of residual root (D7250) Tooth #4, 12 and 13. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested (D2950) Tooth #3 and 5, 
(D6240), Tooth #4, and (D6750) Tooth #3 and 5 are not covered under this benefit. Therefore, we decided that 
the Plan does not have top pre-approve buildup for crown (D2950) Tooth #3 and 5, replacement tooth in a 
bridge (D6240), Tooth #4, and retainer for a bridge (D6750) Tooth #3 and 5.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has pain in their lumbar spine and the 
MRI is medically necessary. The Plan denied your request. The Plan says records do not show the enrollee has 
completed 6 weeks of provider directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
MRI of the lumbar spine is not medically necessary. Our physician reviewer found that the enrollee reported 
lumbar pain that goes down to the legs. An x-ray of sacroiliac (SI) joints from 2020 was normal and the CT of 
the abdomen/pelvis from 2022 showed multi-level disk disease and facet arthrosis. The MRI of the 
pelvis/abdomen found arthrosis in SI joints and advanced degenerative disease in the lumbar spine with 
multilevel spinal canal stenosis. The enrollee was seen by a physical therapist on February 6, 2023. The MRI of 
the lumbar spine was requested. However, although the enrollee appears to have signs and symptoms of lumbar 
radiculopathy, also based on prior imaging, there was insufficient detail documented describing a full 
conservative care treatment plan including formal physical therapy, home exercises, medications, for at least 6 
weeks to justify additional advanced imaging. There was no report of red flag signs or symptoms to warrant 
bypassing this conservative treatment. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on March 
3, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that these services were medically 
necessary and are supported in the medical record. The Plan denied your request. The Plan says the services 
provided would be better reported with a different code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that if the place of service is inconsistent with the procedure code billed, and both codes are valid but 
inconsistent or incompatible with one another, then the claim is returned as unprocessable. 
 
In this case, the CPT Code Manual definition of code 99309 is subsequent nursing facility care, per day. Place 
of service (POS) code 13 is defined as an assisted living facility. 
 
We find that the claim submitted is inconsistent and cannot be processed. Specifically, code 99309 describes 
care that is specifically performed in a nursing facility; however, this claim was submitted with an assisted 
facility setting listed as the place of service. Based on this information, we decided that Medicare rules for 
coverage of subsequent nursing facility care have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent nursing facility care (99309) provided on March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve subchondroplasty. 
 
You asked the Plan to pre-approve subchondroplasty. The Plan denied your request. The Plan says this is 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 subchondroplasty. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that shows the 
requested procedure to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to establish the long-term outcomes for the requested procedure. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested subchondroplasty is 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 subchondroplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve subchondroplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at high risk for falling causing injuries 
which can result in readmission to acute care. You say that the enrollee's needs cannot be safely met with home 
health services or a skilled nursing facility at this time. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and the enrollee's needs can be provided in other settings. 
 
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 that the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: 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. The Plan denied your request. The Plan says the records do not 
show the enrollee needs and are able to take part in 3 hours of therapy a day at least 5 days a week or 15 hours 
per week, services needed can be provided safely in other settings, a skilled nursing facility, home with home 
health services or home with outpatient therapy. 
 
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 documents do not support necessity for admission to an IRF and the complexity of 
the enrollee's nursing, rehabilitation, and medical needs does not require an acute hospital inpatient rehab stay 
with an interdisciplinary approach to rehabilitative 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periapical radiographic image (D0220), and a full mouth 
debridement (D4355), provided on November 29, 2022, to November 30, 2022. 
 
You asked the Plan to pay for a periapical radiographic image, and a full mouth debridement. You say that you 
were told by your dentist that these services would be covered. The Plan denied your request. The Plan says the 
rendered services have been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
periapical radiographic image (D0220), and a full mouth debridement (D4355), provided on November 29, 
2022, to November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeve 
(E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says there is no documentation of swelling that extends onto 
the chest, trunk, or abdomen, use of manual decompression therapy, or a 4-week trial using a basic pneumatic 
compression device (E0650 or E0651). 
 
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) and sleeve (E0667).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 29, 2022, to 
September 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required NOA 
timely. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 29, 2022, to 
September 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on July 2, 2022. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 19, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for radiology services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for radiological services provided on July 2, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Mis 2 continuous glucose monitor 
(CGM) reader. 
 
You asked the Plan to pre-approve a Freestyle Libre Mis 2 CGM reader. You say that the device was ordered to 
monitor the enrollee's diabetes. The Plan denied your request. The Plan says because the member is not using 
any insulin, the requested supplies for a CGM are not a covered benefit of Medicare. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre Mis 2 CGM reader have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Freestyle Libre Mis 2 continuous glucose monitor (CGM) reader.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be provided in other settings. 
 
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 that the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.