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

 
We decided that the Plan has to pay for procedure code 99213-25 provided on June 30, 2022. 
 
You asked the Plan to pay for procedure code 99213-25. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that 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, the CPT Code Manual definition of code 99213 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99213 is supported in the medical record. Specifically, the records document that an 
office visit for the evaluation and management of the enrollee included a medically appropriate history and 
low-level medical decision making on June 30, 2022, the same day as the endovenous ablation therapy (36482) 
provided by the same provider. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99213-25 have been met. Therefore, we decided that the Plan has to pay for procedure code 
99213-25 provided on June 30, 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: 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 medically necessary for you to 
receive aggressive rehab before returning home. The Plan denied your request. The Plan says your needs can be 
met at a lower level of care. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) unit 
(E0730), and electrodes (A9545) provided on June 27, 2022. 
 
You asked the Plan to pay for the TENS unit and supplies. You say that you want to appeal this denial. The 
Plan denied your request. The Plan says the requested items for chronic low back pain are not covered by 
Medicare or the Plan 
 
The Plan must follow Medicare rules. Medicare rules say that TENS) is not reasonable and necessary for the 
treatment of chronic low back pain (CLBP).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS unit and supplies have not been met. Therefore, we decided that the Plan does not have 
to pay for the transcutaneous electrical nerve stimulator (TENS) unit (E0730), and electrodes (A9545) provided 
on June 27, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99308 provided on May 11, 2022. 
 
You asked the Plan to pay for procedure code 99308. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code 99308 based on Medicare criteria. Therefore, we decided that the Plan has to pay 
for procedure code 99308 provided on May 11, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar/sacral transforaminal epidural steroid injection 
(TFESI). 
 
You asked the Plan to pre-approve a lumbar/sacral TFESI. The Plan denied your request. The Plan says the 
medical records do not show at least 50% less pain or functional improvement for at least three months after 
the last injection. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI is indicated when the first injection 
directly and significantly provided improvement of the condition being treated may be considered medically 
reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain 
relief and/or improvement in function measured from baseline using SAME scale for at least three months. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a lumbar/sacral TFESI. Our reviewer 
says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the LCD requires 
for a repeat ESI, at least 3 months of 50% pain relief. Our reviewer found that this was not achieved and 
therefore, the request is deemed not medically reasonable and necessary. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lumbar/sacral TFESI have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar/sacral transforaminal epidural steroid injection (TFESI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H0043 billed for date of service October 31, 
2022, to November 20, 2022. 
 
You asked the Plan to pay for procedure code H0043. You say that this is the correct procedure code. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 H0043 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H0043 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code H0043 billed for date of service October 31, 2022, to November 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 1, 2022, billed 
with codes 81209, 81216, 81223, 81238, 81241, 81242, 81249, 81250, 81279, 81298, 81305, 81307, 81317, 
81320, 81321, 81334, 81339, and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 1, 2022, billed with codes 81209, 81216, 81223, 81238, 81241, 81242, 81249, 81250, 81279, 
81298, 81305, 81307, 81317, 81320, 81321, 81334, 81339, and 81345.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection between wheelchair controller and two or 
more power seating system motors (E2311) and an expandable controller (E2376). 
 
You asked the Plan to pre-approve an electronic connection and expandable controller. You say that you are a 
quadriplegic and have been in an electric wheelchair since you were 16. You also say that you have to tilt so 
you do not pass out, and when it locks up you need help to have the mechanism unlocked so you do not fall out 
of the chair. The Plan denied your request. The Plan says that there is no justification in the service work order 
for an electronic connection between wheelchair controller and two or more power seating system motors and 
an expandable controller. 
 
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 an electronic connection and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the Plan has not provided the disputed work order or 
any information about the existing chair. Our reviewer also found that the Plan's rationale for denial is not 
supported, as there are very limited records and the available records suggest that you do require the requested 
accessories. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection and expandable controller have been met. Therefore, 
we decided that the Plan has to pre-approve an electronic connection between wheelchair controller and two or 
more power seating system motors (E2311) and an expandable controller (E2376).  
 
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: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) provided on November 19, 
2022. 
 
You asked the Plan to pay for the CGM. You say that this should be covered. The Plan denied your request. 
The Plan says that the date of service does not match the delivery date, shipping date, or the date that the label 
was created. 
 
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 contains a valid physician order and proof of delivery for the supplies provided in this case. 
Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) provided on 
November 19, 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve special supplemental benefits for the chronically ill (SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you asked your primary care physician to fill 
out the attestation for the SSBCI benefits. You also say that you do not have the transportation benefit. The 
Plan denied your request. The Plan says that based on the information submitted there is no documentation that 
you meet all 3 criteria for coverage. 
 
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 records do not support that the Plan made multiple attempts to 
obtain medical records from the provider for this case. The records also show that an attestation from the 
provider was sent to the Plan, but this attestation was not provided with this case. This means that the Plan has 
not provided a valid reason for denying payment of the SSBCI benefits. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pre-approve special supplemental benefits for the 
chronically ill (SSBCI).  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the laboratory service provided on November 5, 2022.
  
You asked the Plan to waive the copayment for the lab service. You say that you were told you would not have 
a copayment. The Plan denied your request. The Plan says that that the cost-share was applied correctly. 
 
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. The Plan has not provided an Explanation of Benefits or other documentation 
showing how the cost-sharing was applied. Therefore, we decided that the Plan has to waive the copayment for 
the laboratory service provided on November 5, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an imaging for evaluation of swallowing function (74230), 
provided on November 02, 2022. 
 
You asked the Plan to pay for an x-ray. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services were performed at a nursing home (via mobile van/portable x-ray). 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code assigned by the 
physician/practitioner for the professional component (PC) of a diagnostic services shall be the setting in which 
the enrollee received the technical component (TC) service. 
 
 In addition, POS 11 was billed on the claim, however, documentation received does not support the services 
performed in an office or other outpatient setting but rather in a mobile setting at a SNF. Therefore, the 
decision to deny procedure code 74230 is upheld. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an 
imaging for evaluation of swallowing function (74230), provided on November 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on November 30, 2022. 
 
You asked the Plan to pay for the refraction. You say that your vision deteriorated, and a second refraction was 
needed before 12 months. The Plan denied your request. The Plan says the benefit limit was exceeded. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers this service once a year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for a refraction on March 3, 2022, which 
exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the refraction 
have not been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on 
November 30, 2022.
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 you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says you do not meet the criteria for admission to a 
SNF. 
 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services (A0429, A0425) provided 
on July 29, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says the primary diagnosis submitted on this claim is 
not appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that manifestation codes have a "code first" note and should be sequenced after an appropriate 
etiology code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, the primary diagnosis reported on this claim is 
R65.21 (severe sepsis with septic shock). Diagnosis codes within the R65.2 code set have a "code first" note, 
instructing providers to report the underlying infection before the R65.2 code. This means that it is not appropriate to use this diagnosis code as a primary diagnosis. Therefore, we decided that the Plan does not have 
to pay for ambulance transportation services (A0429, A0425) provided on July 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the enrollee for the total electric hospital bed (E0265), 
shipping (99199), and sales tax (S9999) provided on March 19, 2022. 
 
You asked the Plan to reimburse the enrollee for the durable medical equipment (DME). You say that the 
enrollee's doctor advised which mattress would help with the enrollee's wounds. You say that the hospital 
would not release the enrollee unless the bed was in place. You also say that the previous bed stopped working 
and you could not wait. The Plan denied your request. The Plan says the provider in this case is not a network 
provider. The Plan says that the provider is not certified for Medicare. The Plan also says that payment cannot 
be made for items that were supplied by a provider that is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse the enrollee for the total electric 
hospital bed (E0265), shipping (99199), and sales tax (S9999) provided on March 19, 2022.