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

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on June 
10, 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 99223 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 the medical decision making 
(MDM) is not of high complexity. The MDM included medication management and monitoring, which 
supports moderate 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that BiPAP AVAPS lacks the auto EPAP 
capability the doctor prescribed to concurrently treat the enrollee's known OSA. The Plan denied your request. 
The Plan says the request is not medically necessary because the records show that the ordered settings for the 
noninvasive ventilator can be delivered by a bi-level PAP machine with AVAPS capability. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe obesity. The 
enrollee was recently hospitalized and ABG was consistent with acute on chronic hypercarbic respiratory 
failure, and a diagnosis of obesity hypoventilation syndrome was made. The enrollee also has heart failure with 
reduced ejection fraction and pulmonary hypertension. The enrollee improved with diuresis and noninvasive 
ventilation. There is mention in the record of thoracic restrictive disease, but there is no documentation of 
severe chest deformity or spinal scoliosis. Spirometry was consistent with severe restrictive lung disease. There 
is no diagnosis of COPD or neuromuscular disease. This enrollee may benefit from BiPAP during sleep as an 
outpatient. Medicare does not cover a home ventilator in the treatment of obesity hypoventilation syndrome, or 
when used at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet joint with image guidance, cervical or thoracic; single level (64490) and injection(s), 
diagnostic or therapeutic agent, paravertebral facet joint with image guidance, cervical or thoracic; second level 
(64491). 
 
You asked the Plan to pre-approve injections. You say that you feel the enrollee requires the requested 
procedure. The Plan denied your request. The Plan says the request is not medically necessary because the 
records show the enrollee does not have an absence of untreated radiculopathy. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic neck pain. An MRI of the cervical spine demonstrated multilevel 
subluxations and advanced discogenic disease with minimal cord deformity at C5-C6. There was marked 
multilevel foraminal encroachment and facet arthropathy. She was evaluated on February 24, 2023, for neck 
pain with radiculopathy and her exam demonstrated decreased sensation in the C5-C6 distribution. Anterior 
cervical discectomy and fusion at C5-C6 and C6-C7 were recommended. There is documentation of 
radiculopathy on physical exam. The review has determined that the enrollee does not meet criteria for the 
requested injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet joint with image guidance, 
cervical or thoracic; single level (64490) and injection(s), diagnostic or therapeutic agent, paravertebral facet 
joint with image guidance, cervical or thoracic; second level (64491).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scanning computerized ophthalmic diagnostic imaging  
(code 92134) and intravitreal injection of a pharmacologic agent (separate procedure) (code 67028 LT) 
provided on June 7, 2022 
 
You asked the Plan to pay for scanning computerized ophthalmic diagnostic imaging (code 92134) and 
intravitreal injection of a pharmacologic agent (separate procedure) (code 67028 LT). 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 services at issue were reimbursed 
by the Plan on June 15, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed services were provided twice on the same date. Therefore, we 
decided that the Plan does not have to pay for scanning computerized ophthalmic diagnostic imaging  
(code 92134) and intravitreal injection of a pharmacologic agent (separate procedure) (code 67028 LT) 
provided on June 7, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for diagnostic arteriography/venography rendered 
on September 7, 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 while the clinical record does list hypertension, there is no documentation of systolic 
pressure over 180 or diastolic over 110 and on more than two antihypertensive medications. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this case, anesthesia for diagnostic arteriography/venography is not a Medicare benefit 
for the enrollee's diagnoses. While the clinical record does list hypertension, there was no documentation of 
systolic pressure over 180 mmHg or diastolic over 110 mmHg and on more than two antihypertensive 
medications. The review has determined that the enrollee did not meet the criteria for MAC for CPT 01916. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia for diagnostic arteriography/venography rendered on September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent observation care (code 99226) provided on 
November 10, 2022. 
 
You asked the Plan to pay for subsequent observation care. You say that the patient fell at the construction site 
of future living arrangements and not at work. The Plan denied your request. The Plan says the Plan has 
verified with the member that the injury was a work injury, and that Workers Compensation is responsible. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has verified with 
the enrollee that the injury was a work injury, and that Workers Compensation is responsible. As the secondary 
insurer, the Plan cannot be held responsible for subsequent observation care until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for subsequent 
observation care (code 99226) provided on November 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nasopharyngoscopy with Eustachian tube balloon 
dilation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of 
acute serous otitis media of the right ear, with dysfunction of the Eustachian tube, despite maximal medical 
therapy. He presented to the clinic on January 3, 2023 with an ear infection for two weeks. There is no 
documentation in the submitted records of a tympanogram. In addition, the enrollee has not had documented 
symptoms for greater than 12 weeks, and medical management has not included Valsalva maneuver and 
treatment with nasal or oral steroids. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nasopharyngoscopy with Eustachian tube balloon dilation.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service December 1, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into 
payment for code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service December 1, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatments 
(98941) provided from August 29, 2022, through December 6, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plans denial for payment. The Plan denied your request. The Plan says you do not meet 
criteria for coverage of the services provided. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 issue reimbursement for these services. Our 
reviewer says that the services provided do not meet criteria for payment. Our physician reviewer found that 
you have listed diagnoses of segmental and somatic dysfunction of the cervical, thoracic, lumbar, sacral and 
pelvic regions. The records provided do not document a subluxation of the spine demonstrated by x-ray or 
physical exam. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to issue reimbursement for the chiropractic manipulative treatments (98941) provided from August 29, 
2022, through December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this service is helpful for treatment. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this procedure is the subject of ongoing clinical trials and is considered experimental and 
investigational. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care 
Hospital (LTACH). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan and approved ongoing care in the current 
acute care setting. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on November 14, 
2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that you were assured that the 
provider accepted your insurance. The Plan denied your request. The Plan says this provider does not accept 
Medicare assignment. The Plan contacted this provider and they confirmed that they don't accept Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient 
mental health services provided on November 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for closed treatment of patellar fracture, without manipulation 
rendered on January 6, 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 the code is not appropriate for the service 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 27520 is "Closed treatment of patellar fracture, without 
manipulation." 
 
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 detailed documentation is not 
evident regarding any closed treatment for the fracture being provided in the emergency department. There was 
an order for the application of a long leg splint (knee immobilizer) by the PA; however, it is not clearly 
documented when this was applied or who applied it. Furthermore, the documentation does not corroborate that the PA (physician assistant) or the ER physician were of an orthopedic specialty. Also, the case was noted to be 
discussed (not clear if on phone or in person) with an orthopedic provider. He was scheduled to follow up with 
an orthopedist in the morning. Records of such f/u were not provided. Overall, ongoing follow-up for closed 
treatment/'fracture care' of the patellar fracture is not corroborated by the documentation regarding the date of 
service 1/6/23. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the records do not support that CPT 27520: closed 
treatment of patellar fracture without manipulation was rendered in this case. 
 
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 closed treatment of patellar fracture, without manipulation rendered on January 6, 2022.
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 December 7, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. 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 December 7, 2022.