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

 
We decided that the Plan does not have to pay for procedure code 99220 provided on October 5, 2022. 
 
You asked the Plan to pay for procedure code 99220. You say that the medical records support the billing of 
code 99220. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99220. 
 
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 99220 is Initial observation 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 to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99220. Our reviewer says that the medical 
records do not support the billing of code 99220. Our reviewer found the documentation does not indicate the 
encounter required medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99220 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99220 provided on October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (code 0627T). 
 
You asked the Plan to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level. You say that 
you need this procedure to relieve severe back pain. You say that your back pain is severely debilitating, and 
you can barely walk across a room. The Plan denied your request. The Plan says the requested services are 
considered experimental and investigational. 
 
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 percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic 
guidance, lumbar; first level. Our reviewer says that the requested percutaneous injection of allogeneic cellular 
and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, 
lumbar; first level is not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is an experimental/investigational procedure and therefore, the request is deemed 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 percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous injection of allogeneic 
cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic 
guidance, lumbar; first level (code 0627T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 21, 2022, to 
March 2, 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 
diagnosis code A41.51 is supported. The Plan denied your request. The Plan says the Plan removed diagnosis 
code A41.51 and assigned primary diagnosis N39.0, so they have changed the DRG to 194. 
 
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 A41.51. 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 this inpatient hospital stay does not meet criteria for payment at the billed DRG. Our physician reviewer 
found the enrollee presented with shortness of breath. The enrollee was reported to have no acute distress and 
with lower extremity edema but otherwise normal exam including alert and oriented, without hypoxia. Testing 
was positive for urinary tract infection (UTI). There was no report showing leukocytosis, elevated bilirubin, 
lower platelets, high creatinine, or other abnormality that would describe organ damage/failure. Blood pressure 
was normal. The enrollee - according to the provided documentation - did not meet Sepsis 3 criteria and there 
was no evidence to support that the enrollee experienced a dysregulated response from a systemic infection 
leading organ failure as required. Therefore, diagnosis code A41.51 is not supported for this stay.  
 
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 February 21, 2022, to March 2, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2. 
 
You asked the Plan to pre-approve a Freestyle Libre 2. 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 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Life2000 device is not medically necessary. The Life2000 device is not a true ventilator, because it is not capable of providing full ventilatory 
support. Its intended use is during activity, and not to treat nocturnal hypoventilation and carbon dioxide (CO2) 
retention. There is inadequate evidence of the safety and effectiveness of this device in the treatment of chronic 
obstructive pulmonary disease (COPD). 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on November 9, 
2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
November 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 27, 2022, billed 
with codes 87481, 87491, 87496, 87500, 87529, 87532, 87563, 87591, 87640, 87641, 87651, 87653, 87661 and 
87798. 
 You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the records show that this was a single panel 
which was unbundled and reported with multiple codes. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on June 27, 2022, billed with codes 87481, 87491, 87496, 87500, 
87529, 87532, 87563, 87591, 87640, 87641, 87651, 87653, 87661 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on May 13, 
2022. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the claim should be paid. The Plan 
denied your request. The Plan says the claim was already processed. 
 
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 July 21, 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 the subsequent hospital care have not been met. 
Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on 
May 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Coflex interlaminar stabilization device. 
 
You asked the Plan to pre-approve Coflex procedure. You say that this treatment plan is medically necessary 
and appropriate. The Plan denied your request. The Plan says the clinical value and effectiveness of Coflex 
have not been demonstrated. 
 
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 Coflex procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current evidence-based medical guidelines and peer-reviewed literature do not 
support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a 
lack of large volume, long-term peer-reviewed outcome studies to support the use of the Coflex device for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Coflex procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Coflex interlaminar stabilization device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 the intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the cause of back pain is unclear. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on October 26, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the provider does not participate with Medicare. The Plan also says 
that payment cannot be made for services performed by a provider that does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the outpatient services provided on 
October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation. 
 
You asked the Plan to pre-approve sacroiliac joint radiofrequency ablation. You say that sacroiliac joint 
radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the requested 
sacroiliac joint radiofrequency ablation does 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 sacroiliac joint radiofrequency ablation. 
Our reviewer says that the requested sacroiliac joint radiofrequency ablation is not considered medically 
necessary. Our physician reviewer found that according to the literature, sacral lateral nerve branch blocks 
and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational. Studies completed say that this procedure does not improve outcomes 
compared to standard treatment of sacroiliac joint pain. Radiofrequency ablation for denervation, whether 
performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 sacroiliac joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the heart without 
contrast material scan. 
 
You asked the Plan to pre-approve a CT scan. You say that this CT scan is medically necessary. The Plan 
denied your request. The Plan says this is not a covered CT scan. 
 
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 CT scan. Our reviewer says that a CT 
scan is not medically necessary. Our physician reviewer found CT imaging of the heart without contrast 
material with quantitative evaluation of coronary calcium is considered experimental/investigational for the 
evaluation and management of this enrollee's medical condition. 
 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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) of the heart without contrast material scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the requested drug is not being furnished by a physician and therefore 
is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat transforaminal epidural steroid injections 
(TFESIs). 
 
You asked the Plan to pre-approve TFESIs. You say that the requested TFESI is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents that the first injection provided at least 50% of sustained 
improvement in pain relief for three months. 
 
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 TFESIs. Our reviewer says that the 
requested TFESIs are not medically necessary. Our physician reviewer found the provided documentation does 
not indicate that the enrollee had 50% pain relief for three months with the previous injections. Therefore, the reviewer found that the requested repeat injections were 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 TFESIs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve repeat transforaminal epidural steroid injections (TFESIs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator (E0770). 
 
You asked the Plan to pre-approve a functional electrical stimulator. You say that the enrollee needs this 
device. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage for the use of NMES/FES is limited to SCI 
patients for walking, who have completed a training program which consists of at least 32 physical therapy 
sessions with the device over a period of three months. 
 
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 functional electrical stimulator. Our 
reviewer says that a functional electrical stimulator is not medically necessary. Our physician reviewer found the requested device is only covered for use in individuals with a history of spinal cord injury (SCI) when 
additional criteria for coverage are met. The provided documentation does not indicate you have a history of 
SCI. Therefore, the reviewer found that the requested device 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 a functional electrical stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a functional electrical stimulator (E0770).