Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve stomach surgery. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has dysphagia which is a known complication of nissen fundoplication. The request is for 
surgical reversal of the fundoplication with take down. There is no appropriate assigned CPT code and 
therefore an unlisted code 43999 is reasonable. The patient has failed all conservative treatments and full 
dilation of the gastrojejunal (GJ) will not be possible without takedown of the wrap- full or partial. It is 
medically reasonable and appropriate to consider for this patient as a treatment for complication of nissen 
fundoplication. 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve stomach surgery.  
 
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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for air ambulance services provided on January 27, 2022. 
 
You asked the Plan to pay for the air ambulance services. You say that ground transportation would have been 
dangerous and time consuming. The Plan denied your request. The Plan says that the medical records do not 
support that you could not have been transported via ground ambulance. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
In this case, the facility where you received initial treatment is a Plan-contracted facility.  This facility ordered 
and arranged for the air ambulance transport. In addition, this contracted facility submitted a letter of medical 
necessity explaining why it was necessary for you to be transported via air ambulance. So, you were were 
referred for the air ambulance services by a contract provider. The file does not show that the Plan provided 
notice that the air ambulance services would not be covered. Under Medicare rules, this means the air 
ambulance services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for air 
ambulance services provided on January 27, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services provided to the enrollee on 
November 8, 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 documentation submitted supports a more appropriate code to support the compounded 
administered in an implantable infusion pump. 
 
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 the denied codes is: 
 
CPT 99601: 
 
Home infusion/specialty drug administration, per visit (up to 2 hours) 
 
HCPCS J0735: 
 
Injection, clonidine hydrochloride, 1 mg 
 
HCPCS J1170:  
Injection, hydromorphone, up to 4 mg 
 
HCPCS J3490: 
 
Unclassified drugs 
 
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 terms of CPT 99601, this is a 
non-reportable procedure. In terms of J0735, J1170, and J3490, the documentation includes a compounding 
sheet for "Hydromorphone; Bupivacaine; Clonidine for drug infusion. In this case, there is a more appropriate 
code to report for the services provided. 
 
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 home infusion services provided to the enrollee on November 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthopedic surgery services provided on November 13, 2020. 
 
You asked the Plan to pay for the orthopedic surgery services. You say that you were unaware that your 
provider's office did not submit this claim. The Plan denied your request. The Plan says this claim was not filed 
timely. 
 
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 orthopedic surgery services was not filed until January 25, 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 orthopedic surgery services provided on 
November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 9, 
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 83789-59 (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. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, this code does not appear to 
distinct and independent from Healthcare Common Procedure Coding System (HCPCS) G0480 in this case. 
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 laboratory services provided to the enrollee on 
December 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on December 28, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON podiatry services. You say that the patient told you that she was on 
Medicare. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 podiatry services provided on December 28, 2021 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for medical services provided on August 12, 2021. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says that you need a valid servicing provider National 
Provider Identifier (NPI) to process this claim. 
 
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. Specifically, the Plan's sole rationale for denial is that a valid servicing provider 
NPI is needed.  However, the claim form contained a servicing provider NPI in field 56.  The NPI listed here is 
a valid NPI for the billing organization.  The Plan has provided no evidence as to how or why it determined 
that this NPI was not valid.  The burden is on the Plan to show that its denial is correct.  Absent any evidence 
that this NPI is invalid, we find that the Plan's denial rationale is not supported. Therefore, we decided that the 
Plan has to pay for medical services provided on August 12, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 31 units of code E0562 billed for dates of service August 1, 
2021, to August 31, 2021. 
 
You asked the Plan to pay for 31 units of code E0562. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the records do not support the units 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, you billed with 31 units of code E0562, which is a humidifier used with a continuous positive 
airway pressure machine.  The packing slip and delivery ticket shows that you only provided 1 unit of this item.  
This is a rented item, so only 1 unit for the month should be billed.  You did not bill appropriately for this item.  
The way that you billed would indicate that the patient received 31 separate humidifier units, which is 
incorrect. Based on this information, we decided that Medicare rules for coverage of 31 units of code E0562 have not 
been met. Therefore, we decided that the Plan does not have to pay for 31 units of code E0562 billed for dates 
of service August 1, 2021, to August 31, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency room services provided on January 25, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that you are a Medicare-certified facility. 
The Plan denied your request. The Plan says that because you are not a Medicare-certified facility, this claim 
cannot be paid. 
 
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. Specifically, the Plan's sole rationale for denial is that you are not a Medicare-
certified facility.  However, with your appeal request, you provided a copy of the certification granted to you 
by the Centers for Medicare and Medicaid Services stating that you are certified effective November 24, 2020.  
The Plan has failed to address this certification.  The Plan has failed to provide any documentation that would 
dispute this certification.  The burden is on the Plan to show that its denial is correct and they have failed to do 
so here. Therefore, we decided that the Plan has to pay for emergency room services provided on January 25, 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is considered experimental and investigational. More research is needed. 
 
 
 
 
 
 
 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Minuteman device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 5, 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 provider is billing the professional component modifier on this claim and the technical 
component on a related claim. 
 
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 71046 is "Radiologic examination, chest; 2 views." 
 
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 the medical records include that a 
portable x-ray was performed, and the technical services would be covered. However, the documentation does 
not support the technical services, as that service would be billed by the provider. Services provided are 
separate, and would not be reported together. 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 imaging services provided to the enrollee on August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from October 29, 2021 to 
October 31, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission, the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. Neurology opined that her clinical presentation was likely related 
to complex migraine. She received physical therapy and occupational therapy evaluations, her symptoms 
improved, and she was discharged home on 10/31/2021. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the inpatient hospital services provided from October 29, 2021 to October 31, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the minuteman device is experimental. More research is needed to show safety and efficacy. 
 
 
 
 
 
 
 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Minuteman device.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99233 provided on October 15, 2021. 
 
You asked the Plan to pay for procedure code 99233. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says that the payment for this service is included in 
the fee for the procedure. 
 
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. Specifically, the Plan's sole rationale for denial is that this service is included in 
the fee for the procedure.  The Plan has made no attempts to explain what "the procedure" was, when it was 
rendered, or who provided it.  They have provided no claims as evidence that code 99233 would be included in 
another charge. Based on this, we find that the Plan has failed to substantiate its denial. Therefore, we decided 
that the Plan has to pay for procedure code 99233 provided on October 15, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
December 30, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says additional information is needed to process this claim. 
 
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.  
 
 
 
 
 Although you provided medical records and proof of delivery, the record does not contain a physician order 
which supports medical necessity for the supplies provided in this case. Therefore, we decided that the Plan 
does not have to pay for the continuous glucose monitor (CGM) supplies provided on December 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided to the enrollee on February 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 a modifier was not billed on the claim to represent the services as separate and distinct. 
 
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 73100 
is a column II code to column I code 73110. 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 x-ray services provided to the enrollee on February 6, 2022.