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

 
We decided that the Plan does not have to pay for the anesthesia (99100) provided on May 15, 2021. 
 
You asked the Plan to pay for the anesthesia (99100). You say that the clinical documentation clearly 
demonstrates the medical necessity of the anesthesia billed. You say that the claim was coded appropriately and 
should be reprocessed to pay accordingly. The Plan denied your request. The Plan says bundled services are not 
eligible for separate payment. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia (99100) have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia (99100) provided on May 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and materials (99072) provided on 
October 5, 2021. 
 
You asked the Plan to pay for the additional supplies and materials (99072). You say that plans are required to 
pay non-contract providers at the preferred provider rate when services are not available from preferred 
providers in the service area. You say that the in-network benefits should be honored, and the claim processed 
for payment. The Plan denied your request. The Plan says bundled services are not eligible for separate 
payment. 
 
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 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. 
 
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status 
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the additional supplies and materials (99072) 
have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and 
materials (99072) provided on October 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services billed with Patient-
Driven Payment Model (PDPM) code ODGC1 for dates of service January 10, 2020, to February 14, 2020. 
 
You asked the Plan to pay for the SNF services. You say that these services were reported correctly. The Plan 
denied your request. The Plan says the documentation does not support the PDPM billed. 
 
 The Plan follows Medicare rules. Medicare rules say that SNF providers must bill the appropriate PDPM codes 
to represent the patient's condition during the SNF stay. 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 SNF services. Our reviewer says that the PDPM code billed is not supported. Our physician 
reviewer found the first alphanumeric character "O" equals Non-Ortho Surgical and Acute Neurologic & a 
therapy function score of 10-23. According to the documentation provided, Section GG, Functional Abilities 
and Goals - Admission, is dated 1/13/2020, and is unsigned by the provider. Therefore, this character is not 
supported. The third alphanumeric character "G" equals Special Care High and the patient has a physician 
documented and active diagnosis of chronic obstructive pulmonary disease (COPD) and also experienced 
shortness of breath when lying flat and a Nursing function score of 6-14. The patient's records document 
dyspnea while lying flat, along with diagnoses of Asthma, COPD or chronic lung disease, and respiratory 
failure. For the fourth alphanumeric character "C", this equals NTA score of 6-8 for the coding of Diabetes 
mellitus, COPD, Malnutrition or At risk for Malnutrition, Chronic respiratory failure with hypoxia, and 
Immunodeficiency, unspecified. The available documentation in the case file does not have signed physician 
documentation that supports that the enrollee had malnutrition, or was at risk for malnutrition, nor does it 
contain documentation that supports that malnutrition was an active problem for the enrollee during the look 
back period. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services billed with Patient-Driven Payment Model (PDPM) 
code ODGC1 for dates of service January 10, 2020, to February 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance services provided on November 
19, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance services. You say that the patient was transported 
from the hospital to the nursing home following treatment for aggressive behavior. The Plan denied your 
request. The Plan says these ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the non-emergency ambulance services. Our 
reviewer says that these ambulance services were not medically necessary. Our physician reviewer found the 
patient is a 67 year old male who has a history of dementia and schizophrenia who was recently treated in the 
hospital for aggressive behavior. He was transported via ambulance from the hospital to a skilled nursing 
facility. The patient's vitals were stable. He walked with assistance to the cot and the trip was without incident. He did not receive any treatment during transport. The doctor says that other means of transport were not 
contraindicated. 
 
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 non-emergency ambulance services have not been met. Therefore, we 
decided that the Plan does not have to pay for non-emergency ambulance services provided on November 19, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says there is no indication 
the member has had an osteoporosis-related fracture or that the member has tried and failed zoledronic acid. 
 
  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found that the record indicates that the enrollee has age related osteoporosis without history 
of osteoporotic fracture. The provided records do not indicate that the enrollee has tried and failed the plan's 
preferred step one alternative. The record also does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390), purchased on October 15, 
2021. 
 
You asked the Plan to pay for the oxygen concentrator. You say that the item should be covered. The Plan 
denied your request. The Plan says an oxygen concentrator is only covered when rented. 
 
The Plan must follow Medicare rules. Medicare rules say that for oxygen and oxygen equipment, contractors 
pay a monthly fee schedule amount per beneficiary. Unless otherwise noted below, the fee covers equipment, 
contents and supplies. Payment is not made for purchases of this type of equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen concentrator have not been met.  
 
 
 
 Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390), purchased on 
October 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found at the current level of function, your rehabilitation can be safely provided at a lower 
intensity and alternate setting such as in a skilled nursing facility. Documentation does not support the necessity for admission to an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) vaccine (90715 and 90471) provided on November 17, 2021. 
 
You asked the Plan to pay for the Tdap vaccine. You say that you would like reconsideration because your 
provider told you that this vaccine was a good idea. The Plan denied your request. The Plan says this 
vaccination is not covered when billed with a non-covered diagnosis. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. 
Therefore, we decided that the Plan does not have to pay for tetanus, diphtheria toxoids and acellular pertussis 
vaccine (Tdap) vaccine (90715 and 90471) provided on November 17, 2021.  
 
Benefits for the Tdap vaccine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. 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 a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says 
that the item is not medically necessary. Our physician reviewer found the documentation is conflicting on your 
functional ability and mobility deficit. The January 28, 2022, physician notes states that you maintain the 
ability to get dressed, lift arms above head, lift legs, move in house/home, transfers and independent self-care is 
still possible. Your mobility is noted as normal. The same document also states that you can walk very little 
and is wheelchair confined.  The documentation does not reveal upper extremity strength or range of motion (ROM) deficits that would 
limit use of a manual wheelchair or that a caregiver is unable to propel a manual wheelchair. The 
documentation does not reveal a home assessment to support that the requested device will be able to safely 
maneuver in the home and access rooms for MRADL participation. The documentation does not support that 
the item will significantly improve your ability to participate in MRADLs. The documentation does not reveal 
that the requested item is medically necessary per Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (95969, 95870), somatosensory 
testing (95938), central motor evoked potential study (95939) and continuous intraoperative neurophysiology 
monitoring in the operating room (95940) provided on September 1, 2021. 
 
You asked the Plan to pay for the neuromonitoring services. You say that you would like reconsideration 
because you received prior authorization for these services. The Plan denied your request. The Plan says this 
charge is included in the facility benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the neuromonitoring services have not been met. Specifically, the record indicates that the member 
was registered inpatient on the billed date of service. As such, the place of service code billed on this claim is 
inappropriate. Additionally, payment for these services is included in the payment to the facility and is the 
responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for needle 
electromyography (95969, 95870), somatosensory testing (95938), central motor evoked potential study 
(95939) and continuous intraoperative neurophysiology monitoring in the operating room (95940) provided on 
September 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 11, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
contacted the Plan about the bill you received and were advised that the company would pay $235.00 towards 
the total bill of $471.00. The Plan denied your request. The Plan says the Plan only covers ambulance transport 
to the nearest appropriate facility that can provide care according to your plan benefits. The Plan also says that 
your plan does not cover ambulance services where no transport occurs. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 11, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiofrequency ablation (RFA) of the sacroiliac (SI) joint 
provided on December 1, 2021. 
 
You asked the Plan to pay for RFA of the SI joint. You say that RFA of the SI joint was medically necessary. 
The Plan denied your request. The Plan says this service was 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 pay for RFA of the SI joint. Our reviewer says that 
RFA of the SI joint is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has sacroiliac pain. The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The requested 
service has not been shown to be safe and efficacious, as defined by Medicare rules, 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 RFA of the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pay for radiofrequency ablation (RFA) of the sacroiliac (SI) joint provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided at 24-hour facility in addition to basic 
service (99053) provided on September 4, 2021. 
 
You asked the Plan to pay for the services provided at 24-hour facility in addition to basic service (99053). You 
say that the correct CPT code was billed, and no coding change is required. You say that medical records are 
attached, and the claim should be reconsidered for payment. The Plan denied your request. The Plan says 
bundled services are not eligible for separate payment. 
 
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 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. 
  We find that CPT code 99053 is not supported in the medical record. Specifically, CPT code 99053 has a status 
indicator of B. This means that CPT code 99053 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the services provided at 24-hour facility in 
addition to basic service (99053) have not been met. Therefore, we decided that the Plan does not have to pay 
for the services provided at 24-hour facility in addition to basic service (99053) provided on September 4, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance transport provided on June 18, 
2021. 
 
You asked the Plan to pay for the non-emergency ambulance transport. You say that this claim should be paid. 
The Plan denied your request. The Plan says this transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the non-emergency ambulance transport. 
Our reviewer says that this transport was not medically necessary. Our physician reviewer found the patient is a 
74 year old female who was transported via ambulance from the hospital to a location for a sleep study. Her 
vitals were stable with no complaints. She was bed-confined and has a history of atrial fibrillation. She received 
no treatment during transport that was without incident.  The doctor says that other methods of transportation 
were not contraindicated for the patient.  
 
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 non-emergency ambulance transport have not been met. Therefore, we 
decided that the Plan does not have to pay for non-emergency ambulance transport provided on June 18, 2021.