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

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital inpatient or observation discharge day management; 
more than 30 minutes provided to the enrollee on July 12, 2021. 
 
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 the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 99239 is "Hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter." 
 
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 in this case, there is no 
documentation of a complex hospital discharge note that would support the billing code for 99239. 
 
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 hospital inpatient or observation discharge day management; more than 30 minutes provided to 
the enrollee on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for professional services for the supervision of preparation and 
provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses) 
provided to the enrollee on April 5, 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 Current Procedural Terminology (CPT) code 95165 (30 units) remains 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 95165 is "Professional services for the supervision of 
preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number 
of doses)." 
 
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 documentation simply states that an injection was performed but there is no documentation of that was injected who injected or the where it 
was injected. The documentation does not support the use of CPT 95165. 
 
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 professional services for the supervision of preparation and provision of antigens for allergen 
immunotherapy; single or multiple antigens (specify number of doses) provided to the enrollee on April 5, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a walking boot, pneumatic and/or vacuum, with or without joints, with 
or without interface material, prefabricated, off-the-shelf (L4361) provided to the enrollee on May 24, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that if the basic coverage criteria is not met, the orthosis will be denied as not reasonable 
and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that that AFOs can be approved for those who require 
stabilization for medical reasons and have the potential to benefit functionally. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation indicates that the enrollee is requiring the AFO post-operatively and 
to help stabilize the joint while he remains non-weightbearing. There was an indication that the AFO was 
required for stabilization for medical reasons or that there was a potential to benefit the member functionally. 
The requested AFO orthosis was 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 services have been met. Therefore, we decided that the Plan has to pay for a 
walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, 
prefabricated, off-the-shelf (L4361) provided to the enrollee on May 24, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99231 billed for date of service May 10, 2022. 
 
You asked the Plan to pay for code 99231. You say that you would like this claim reprocessed. The Plan denied 
your request. The Plan says you did not supply medical records to support payment of this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of code 99231 have been met. 
Specifically, although your appeal request seems to indicate that you supplied medical records, no records were 
actually attached to your submission.  Without medical records, we cannot determine if the services were medically necessary or if they were coded correctly.. Therefore, we decided that the Plan does not have to pay 
for code 99231 billed for date of service May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch block injections. 
 
You asked the Plan to pre-approve medial branch block injections. You say that medial branch block injections 
are medically necessary. The Plan denied your request. The Plan says medial branch block injections do not 
meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve medial branch block injections. Our 
reviewer says that medial branch block injections are not medically necessary in this case. Our physician 
reviewer found that the presence of radiculopathy does meet the Medicare LCD criteria for performing facet 
blocks. The enrollee has multiple other probable pain generators. Therefore, the request does not meet the 
Medicare LCD criteria and is not medically 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 medial branch block injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve medial branch block injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp vitality tests (D0460), and local anesthesia in 
conjunction with operative or surgical procedures (D9215) provided on October 25, 2022. 
 
 You asked the Plan to pay for pulp vitality tests (D0460), and local anesthesia in conjunction with operative or 
surgical procedures (D9215). You say that you were misinformed by two Plan representatives who stated you 
would be covered for a malpractice root canal procedure with a remaining balance of $3,376. The Plan denied 
your request. The Plan says these services are not covered under the benefit package. 
 
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 pulp 
vitality tests (D0460), and local anesthesia in conjunction with operative or surgical procedures (D9215) 
provided on October 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted single panel provided to the enrollee on May 27, 
2022. 
 
You asked the Plan to pay for the panel. You say that this was medically necessary. The Plan denied your 
request. The Plan says tests performed on patients without signs or symptoms to determine risk for developing 
a disease or condition are not considered a Medicare benefit and are statutorily excluded. 
 
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 panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this test was done for screening purposes, which is not a covered benefit. There is no documentation 
of medical indication from the treating provider. The review has determined that the enrollee did not meet the 
coverage criteria for this request. 
 
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 panel have not been met. Therefore, we decided that the Plan does not have 
to pay for a targeted single panel provided to the enrollee on May 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System. 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this 
time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (procedure code 97110) provided to the 
enrollee on August 18, 2021. 
 
You asked the Plan to pay for the services. You say that this should bep aid for. The Plan denied your request. 
The Plan says the code is not appropriate for the services 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. 
 
In this case, the CPT Code Manual definition of code 97110 is "Therapeutic procedure, 1 or more areas, each 
15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility." 
 
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 medical records provided 
indicate that the services performed were done in a home health or hospice setting by a physical therapist; 
therefore, it is inappropriate to bill 97710 GP KX for the services rendered. 
 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 therapy services (procedure code 97110) provided to the enrollee on August 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided on September 13, 2022. 
 
You asked the Plan to pay for critical care services. The Plan denied your request. The Plan says Medicare is 
responsible for hospice payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on September 12, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for critical care services 
provided on September 13, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on March 18, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
the claim does not meet the urgent or emergent criteria based on the codes submitted. The member does not 
have out of network benefits. There is no documentation this member was referred to this non-contracted 
provider by a contracted provider, as well as no indication any attempt was made to obtain prior authorization 
for the out of network services. 
 
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 or rest home visit provided on March 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies billed with code A4594 for 
September 8, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 electrical stimulator supplies billed with code A4594 for 
September 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9502 billed for date of service July 30, 
2022 to August 2, 2022. 
 
You asked the Plan to pay for procedure code S9502. You say that you were told this service was covered. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9502 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9502 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9502 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9502 billed for date of service July 30, 2022 to August 2, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for EEG testing procedures (code 95957), nerve conduction tests  
(code 95908), electromyography procedures (CPT 95886), and short-latency somatosensory evoked potential 
study (code 95938) provided on May 20, 2022. 
 
You asked the Plan to pay for EEG testing procedures, nerve conduction tests, electromyography procedures, 
and short-latency somatosensory evoked potential study. You say that you have provided the medical records 
that were requested so the claim can process appropriately. The Plan denied your request. The Plan says that in 
a prior communication to you, we requested specific information in order for us to complete our review. We 
need all treatment records, which should include intraoperative monitoring report and operative report. 
 
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 has not provided the information that the Plan still required after the 
medical records were provided with the appeal case. Therefore, we decided that the Plan has to pay for EEG 
testing procedures (code 95957), nerve conduction tests (code 95908), electromyography procedures (CPT 
95886), and short-latency somatosensory evoked potential study (code 95938) provided on May 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.