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

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service October 1, 
2022 to October 2, 2022. 
 
You asked the Plan to pay for procedure code 99291. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service October 1, 2022 to October 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service August 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS 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 there is not enough evidence that this requested device would improve outcomes. 
 
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 that at issue is the medical appropriateness and necessity of implantation of the wireless pulmonary 
artery pressure monitoring system (CardioMEMS) for management of congestive heart failure in this patient. 
There remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS 
system would not be considered medically appropriate and necessary in this patients clinical management. 
 
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 CardioMEMS device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from June 24, 2022, to 
July 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnoses are not supported. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that billed secondary diagnosis codes N18.4, J44.9, 
and I13.10 are not supported. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services rendered from June 24, 2022, to July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99219 billed for date of service March 12, 
2022. 
 You asked the Plan to pay for procedure code 99219. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99219 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99219 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99219 billed for date of service March 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve additional service image guidance (77014, 77387). 
 
You asked the Plan to pre-approve additional service image guidance. You say that the services are necessary. 
The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 additional service image guidance. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found for radiation in the definitive setting, image-guided radiation therapy (IGRT) 
could be considered medically necessary when escalating the dose (as is done with curative treatment), or when 
critical normal tissues abutting the target necessitate daily image guidance to allow minimal planning margins 
to spare the normal tissue. In this case, the daily computed tomography (CT) scan can verify alignment of the 
bladder and rectum on a day to day basis and seems consistent with accepted standards of care. It would 
therefore meet the standard medical necessity criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional service image guidance have been met. Therefore, we decided that 
the Plan has to pre-approve additional service image guidance (77014, 77387).  
 
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: Favorable

 
We decided that the Plan has to pre-approve diagnostic facet injections. 
 
You asked the Plan to pre-approve diagnostic facet injections. You say that the requested facet joint 
intervention (64493 and 64494) is medically necessary. The Plan denied your request. The Plan says that the 
enrollee does not meet criteria for the requested facet joint intervention (64493 and 64494). 
 
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 diagnostic facet injections. Our 
reviewer says that the enrollee meets criteria for the requested facet joint intervention (64493 and 64494). Our 
physician reviewer found the enrollee has chronic axial low back pain and sacroiliac (SI) joint pain. She takes 
Robaxin, Tylenol and had a brief course of Hydrocodone. She is doing physical therapy (PT) and a home 
exercise program. Physical exam shows SI joint pain and facet mediated pain. Negative straight leg raising test. 
She had an SI joint injection as well as piriformis injection. An x-ray of her lumbar/spine shows there is loss of 
disc space at L4-L5 and L5-S1. Marginal osteophytes are present and involve the contiguous vertebral bodies 
from the level of L3 to the level of S1, Facet joint sclerosis is present at L3-L4, L4- L5 and L5-S1. Findings are 
consistent with degenerative spondylo-arthrosis. The request is for diagnostic facet injections. The enrollee has 
facet mediated pain as shown on Physical exam and imaging. The request is 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 diagnostic facet injections have been met. Therefore, we decided that the Plan 
has to pre-approve diagnostic facet injections.  
 
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 electrical nerve stimulation supplies billed with code 
A4595 for July 1, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the electrical nerve stimulation supplies billed with code 
A4595 for July 1, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service June 6, 2022. 
 
You asked the Plan to pay for procedure code 11721. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 11721 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 11721 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 11721 billed for date of service June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99204 provided on August 22, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are 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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the documentation shows 
that the enrollee was not a new patient. This means this code is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we 
decided that the Plan does not have to pay for the office visit coded 99204 provided on August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, & 88360 billed for date of 
service February 24, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, & 88360. You say that this service was 
medically necessary. The Plan denied your request. The Plan says this code is included in the facility payment 
and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, & 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, & 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, & 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, & 88360 billed for date of service February 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that Botox is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic migraines 
without aura. The record provided does not indicate that there is nausea, vomiting, or photophobia. The record 
provided is insufficient to determine that the coverage criteria elements are satisfied. Botox is therefore not 
reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D testing coded as 88361, 88312, 88305 
provided August 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that WATS 3Dcannot be considered 
experimental or investigational since it is established in standard of practice guideline of major medical society 
and has been found to be safe and effective for the guideline recommended indication. The Plan denied your 
request. The Plan says this testing is considered 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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has with a history of GERD. Per the literature, esophageal brush biopsy (WATS3D, formerly known as EndoCDx) is considered experimental and 
investigational for screening, diagnosis or surveillance of cancerous or pre-cancerous esophageal lesions 
because of insufficient evidence. The review has determined that the items/services at issue in this case are not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the WATS 3D testing coded as 88361, 88312, 88305 provided August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on 
October 6, 2022. 
 
You asked the Plan to pay for the pre-diagnostic test. You say that you disagree with the denial of the oral 
cancer screening. The Plan denied your request. The Plan says that an adjunctive pre-diagnostic test (D0431) is 
not covered by your dental benefits. 
 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
adjunctive pre-diagnostic test (D0431) provided on October 6, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for computed tomography, cervical spine; without contrast material 
(procedure code 72125) provided to the enrollee on September 18, 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 that payment for this service is included in the payment/allowance for another service/procedure 
that has already been adjudicated. 
 
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 72125 is "Computed tomography, cervical spine; without contrast material." 
 
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 supported by the medical records. Our reviewer found that the records show that a single unit of 
CPT 72125 was done on this date of service. The records support this service. 
 
We looked at this coder's review, the file, and Medicare rules. The records support the use of this code. The 
plan has not specified what other services are inclusive to the denied code. The plan has not fully substantiated 
their denial in this case. Based on this information, we decided that Medicare rules for coverage of the services 
have been met. Therefore, we decided that the Plan has to pay for computed tomography, cervical spine; 
without contrast material (procedure code 72125) provided to the enrollee on September 18, 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: Favorable

 
We decided that the Plan has to pay for the subsequent hospital care services provided on June 13, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that the procedure was incorrectly coded. 
 
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. Review of the file shows that the Plan states that the procedure was incorrectly 
coded. However, the documentation did not include explanation of why this procedure was incorrectly coded. 
The Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the subsequent 
hospital care services provided on June 13, 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 the chiropractic manipulative treatments (98941) provided on 
July 26, 2022 and July 29, 2022. 
 
You asked the Plan to pay for these services. You say that the chiropractic manipulative treatments provided 
were medically necessary. The Plan denied your request. The Plan says you do not meet medical necessity 
criteria for coverage of the services provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 these services. Our reviewer says that the 
chiropractic services provided were not medically necessary. Our physician reviewer found that in this case, the 
record indicates that you have a lumbar subluxation. The record provided does not indicate that you are 
receiving active treatment but maintenance therapy as further clinical improvement cannot be reasonably 
expected from ongoing care. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the chiropractic manipulative treatments (98941) provided on July 26, 2022 and July 29, 2022.