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

 
We decided that the Plan does not have to pay for hospital discharge day management services (procedure code 
99239) provided to the enrollee on November 19, 2021 and November 20, 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 Current Procedural Terminology (CPT) code 99239 (1 Unit) 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 99239 is "Hospital discharge day management; more than 
30 minutes." 
 
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 record includes 
documentation of services provided on dates of service other than November 20, 2021, and therefore, service 
billed cannot be verified.  
 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 discharge day management services (procedure code 99239) provided to the enrollee 
on November 19, 2021 and November 20, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from May 21, 2021, 
to May 30, 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 that the provider has reported inpatient hospital services with the incorrect DRG. 
 
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 DRG 330 (MAJOR SMALL AND LARGE 
BOWEL PROCEDURES WITH COMPLICATION OR COMORBIDITY). 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 services at issue in this case were 
supported by the medical records. Our physician reviewer found that the documentation of symptoms and 
physical findings supports a clinical diagnosis of a postoperative ileus. A diagnosis of acute kidney failure, also 
called acute kidney injury, is supported by the clinical record, with a documented elevation of creatinine of 1.5 
times baseline. Diagnosis code D56.7 and N17.9 were supported by the medical records. The use of DRG 330 
is supported by the medical records in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided to the enrollee from May 21, 2021, to May 30, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits, acupuncture and physical therapy provided 
on November 12, 2021, and December 31, 2021. 
 
You asked the Plan to pay for the office visits, acupuncture and physical therapy. You say that you called 
before scheduling an acupuncture appointment and was told it would be covered. The Plan denied your request. 
The Plan says services other than manual manipulation of the spine are not covered. 
 
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.  
 
 
  The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visits, acupuncture and physical therapy provided on November 12, 
2021, and December 31, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee received oral medications, had 
stable vital signs and he continued dialysis. The enrollee was at a modified independent to contact guard assist 
level for functional mobility including gait to 250 feet. The enrollee does not require skilled nursing or therapy 
services on a daily basis. He does not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit received on December 17, 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 spinal manipulations are only covered for subluxation of the spine. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit received on December 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on January 7, 2022. 
 
You asked the Plan to pay for the drugs. You say that the department that denied the claim should have sent it 
to the Part D prescription plan for payment. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Genicular nerve block (64454). 
 
You asked the Plan to pre-approve a Genicular nerve block. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says the requested procedure does not meet criteria. 
 
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 Genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee declined a total knee replacement several years ago but is no longer 
considered an acceptable candidate for TKR. This is an experimental/ investigational procedure whose role in 
the management of osteoarthritis of knee is still being investigated. 
 
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 Genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Genicular nerve block (64454).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psych diagnostic evaluation provided to the enrollee on 
November 4, 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 hospice was elected on 11/4/21. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a psych diagnostic evaluation provided to the enrollee on 
November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on 
September 13, 2021. 
 
You asked the Plan to pay for the office visit. You say that a referral was sent more than once but you keep 
getting billed. The Plan denied your request. The Plan says the service was not approved in advance and a 
referral for out-of-network services was not received. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided by an out-of-network 
provider on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on August 4, 
2020. 
 
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 claim was filed past the allowed 12 month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until February 4, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for anesthesia services provided to the enrollee on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on September 23, 2021, billed with 
codes 87150 and 87641. 
 You asked the Plan to pay for the lab testing as billed. You say that this was medically necessary testing. The 
Plan denied your request. The Plan says two of the billed codes were not reported with a modifier to bypass the 
edit pair. 
 
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 87150 
is a column II code to column I code 87500, and 87641 is a Column 2 code in relation to 87150. This claim has 
not been billed with appropriate modifiers to bypass the edits. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided 
on September 23, 2021, billed with codes 87150 and 87641.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from November 1, 2021, through 
December 1, 2021. 
 
You asked the Plan to pay for SNF services. You say that you were told pre-certification was not required and 
the claim should be reconsidered for payment. The Plan denied your request. The Plan says the provider has 
not submitted any clinical records to support the medical necessity of the services. 
 
  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 SNF services provided from 
November 1, 2021, through December 1, 2021. have been met. Specifically, medical records were not 
submitted to determine if criteria for coverage of SNF services have been met. Therefore, we decided that the 
Plan does not have to pay for SNF services provided from November 1, 2021, through December 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81295 and 81298) provided on 
November 14, 2021. 
 
You asked the Plan to pay for codes 81295 and 81298. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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, we have confirmed that codes 
81295 and 81298 are column II codes to column I code 81432 with a modifier indicator of 0. The column II 
codes are therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (81295 and 81298) 
provided on November 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (L3960) provided on August 
31, 2021. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (L3960) provided on August 31, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound repair (12052) and complex repair (13132 and 13133) 
provided on December 3, 2021. 
 
You asked the Plan to pay for wound repair (12052) and complex repair (13132 and 13133). You say that 
additional information is attached, and the claim should be reviewed for prompt payment. The Plan denied your 
request. The Plan says the modifier was not billed on the secondary codes to bypass the edit. 
  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 codes 
12052, 13132 and 13133 are column II codes to column I code 36620. 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 wound repair (12052) and complex repair 
(13132 and 13133) provided on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88329-26) provided on January 11, 
2022. 
 
You asked the Plan to pay for code 88329-26. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as 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. 
 
We looked at the file and Medicare rules. The PC/TC indicator for CPT code 88329-26 is "0" = Physician 
service codes. This indicator identifies codes that describe physician services. Examples include visits, 
consultations, and surgical procedures. The concept of PC/TC does not apply since physician services cannot 
be split into professional and technical components. Modifiers 26 & TC cannot be used with these codes. The 
total Relative Value Units (RVUs) include values for physician work, practice expense and malpractice 
expense. There are some codes with no work RVUs. Each NCCI PTP edit has an assigned modifier indicator. 
A modifier indicator of "0" indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit. In 
this case, CPT code 88329-26 has a modifier indicator of 0. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (88329-26) provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that purified natural hyaluronans have been approved by 
the FDA for the treatment of pain associated with osteoarthritis of the knee in patients who have failed to 
respond adequately to conservative nonpharmacologic therapy and simple analgesics. 
 
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 Gelsyn-3. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found hyaluronic acids (such as Gelsyn-3) are 
naturally occurring substances in the body's connective tissues that cushion and lubricate the joints. Intra-
articular injection of hyaluronic acid can decrease symptoms of osteoarthritis of the knee. Intra-articular 
injections with hyaluronic acid are recommended as a possible option for severe osteoarthritis for patients who 
have not responded adequately to recommended conservative treatments. While osteoarthritis of the knee can 
be a recommended indication, there is insufficient evidence for other conditions. The review has determined 
that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic CGM (CPT code K0553) provided on December 
6, 2021. 
 
You asked the Plan to pay for the CGM. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the CGM have not been met. The medical records submitted with 
the appeal shows that the item shipped on December 7, 2021, and delivered on December 11, 2021. The date of 
service of December 6, 2021, for the claim does not match the shipping information. Therefore, we decided 
that the Plan does not have to pay for therapeutic CGM (CPT code K0553) provided on December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. 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 for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 a CGM have been met. Specifically, 
medical records were not received. Without this documentation, medical necessity cannot be established. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-invasive physiologic studies of upper or lower extremity 
arteries, duplex scan of lower extremity arteries or arterial bypass grafts, and office visit 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 services were not urgent or emergent. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for non-invasive physiologic studies of upper or lower 
extremity arteries, duplex scan of lower extremity arteries or arterial bypass grafts, and office visit provided to 
the enrollee on July 12, 2021.