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

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on November 23, 2022. 
 
You asked the Plan to pay for initial hospital care (99223). You say that the procedure code was coded and 
billed accurately. The Plan denied your request. The Plan says the medical records submitted do not support a 
comprehensive history. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 initial hospital care (99223). Our reviewer says that 
procedure code 99223 is not supported. Our reviewer found the documentation does not clearly support a 
comprehensive history or physical and does not support decision-making of high complexity.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care (99223) have not been met. Therefore, we decided that the 
Plan does not have to pay for initial hospital care (99223) provided on November 23, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a pneumatic compression device (PCD) (E0652) and accessory 
(E0667). 
 
You asked the Plan to pre-approve the PCD and accessory. The Plan denied your request. The Plan says that 
this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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 PCD and accessory. Our reviewer 
says that the requested PCD and accessory are medically reasonable and necessary. Our physician reviewer 
found that the enrollee has lymphedema and a history of deep vein thrombosis (DVT) having failed 
conservative treatment. The provided records describe the enrollee with abdominal/truncal edema. Also, the documentation shows record of a failed attempt at using a basic compression pump (not segmented) as it 
caused worse truncal edema and scrotal edema, exacerbating symptoms instead of improving them. Therefore, 
this request for PCD E0652 and accessory E0667 will be considered medically reasonable and necessary at this 
time based on the provided documentation. 
 
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 PCD and accessory have been met. Therefore, we decided that the Plan has 
to pre-approve a pneumatic compression device (PCD) (E0652) and accessory (E0667).  
 
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 pre-approve electrical stimulation (the Sanexas procedure). 
 
You asked the Plan to pre-approve the Sanexas procedure. You say that you are appealing the denial of this 
service. The Plan denied your request. The Plan says that the service is 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 pre-approve the Sanexas procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is not enough evidence to support its effectiveness. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electrical stimulation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electrical stimulation (the Sanexas procedure).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on January 
16, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have billed the services 
at issue correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
  The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to ESRD provided on January 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injections (27096). 
 
You asked the Plan to pre-approve sacroiliac joint injections. You say that sacroiliac joint injections are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says sacroiliac joint injections are 
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 pre-approve sacroiliac joint injections. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Medicare criteria for coverage require the documentation of 3 diagnostic 
provocative joint maneuvers. This documentation is not present in the medical records provided. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacroiliac joint injections (27096).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect test (0012M) provided January 18, 
2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial of coverage for 
the Cxbladder Detect test for the enrollee. The Plan denied your request. The Plan says the CX Bladder panel 
remains unproven at this time. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Cxbladder Detect test (0012M) provided January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital intravenous infusion 
services provided from December 22, 2022, to December 24, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital intravenous infusion services. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 You have been asked to pay the allowed amount of $249.31 for each date of service, which is less than the 
$350 copayment for outpatient hospital intravenous infusion services. This service falls within the Outpatient 
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient hospital 
intravenous infusion services provided from December 22, 2022, to December 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopy, surgical, esophagogastric fundoplasty 
(43280). 
 
You asked the Plan to pre-approve the surgical service. You say that you want to appeal this denial. The Plan 
denied your request. The Plan says this procedure is 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 pre-approve the surgical service. Our reviewer says 
that the requested surgical service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not support the medical necessity of the requested 
procedure. The reviewer found that the provided documentation showed only a small hiatal hernia and 
esophagitis was only mild-to-moderate. Therefore, the reviewer found that the requested surgical service is 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 surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a laparoscopy, surgical, esophagogastric fundoplasty (43280).
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 you need the services to learn how to take care of 
yourself again. The Plan denied your request. The Plan says you do not meet the criteria for admission to an 
IRF.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service March 1, 
2023. 
 You asked the Plan to pay for procedure code 87640. The Plan denied your request. The Plan says payment for 
code 87640 is bundled into payment for code 87641. 
 
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 87640 
is a column II code to column I code 87641. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 87640 billed for date of 
service March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low-level laser treatment (S8948) provided on March 14, 
2023. 
 
You asked the Plan to pay for the laser treatment. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this is not a covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the low-level laser treatment (S8948) provided on March 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxervate. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary for the 
enrollee's diagnose. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxervate.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the aflibercept injection provided on 
January 25, 2023. 
 
You asked the Plan to waive the coinsurance for the aflibercept injection. You say that you disagree with the 
cost sharing amount. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the aflibercept injection. This item/service falls within the 
Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $733.04 ($3,665.18 allowed amount x 20% coinsurance = $733.04). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the aflibercept injection 
provided on January 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an open implantation of neurostimulator electrode array; 
sacral nerve (transforaminal placement) (64581). 
 
You asked the Plan to pre-approve the surgical service. You say that your condition interferes with your job, 
social interactions, and is extremely disruptive. You say that the supplies and medications for your condition are very costly. You also say that this procedure is necessary for your quality of life. The Plan denied your 
request. The Plan says this procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation is covered when certain 
criteria have been 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 the surgical service. Our reviewer says 
that the requested surgical service is not medically necessary. Our physician reviewer found the provided 
documentation does not show that the enrollee has tried any behavior therapy or biofeedback regimens. The 
documentation does not show that the stress incontinence has been treated. The records also do documentation 
does not show that the enrollee has tried and failed or is not a candidate for surgery to tighten the proper 
muscles. Therefore, the reviewer found that the requested implantation of neurostimulator electrode array is 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 surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an open implantation of neurostimulator electrode array; sacral nerve (transforaminal 
placement) (64581).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have  to pay for a pneumatic compression device (E0676). 
 
You asked the Plan  to pay for a pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have  to 
pay for a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 00752. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 99100.  
 
You asked the Plan to pay for Practitioner services provided on January 24, 2023, billed with procedure codes 
99100 and 00752. You say that the claim is billed correctly and should be paid. The Plan says that this is an 
unbundled service. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 00752.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 00752.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99100. 
 
The Plan follows Medicare rules. Medicare rules say that the Physician Fee Schedule Status Indicator B means 
that payment for covered services is always bundled into payment for other services. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 99100 have not been met. Code 99100 has a status 
indicator B and is not separately payable. Therefore, we decided that the Plan does not have to pay for the 
services described by procedure code(s) 99100. 
 
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 a Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that  this procedure is medically 
necessary for the enrollee. The Plan denied your request. The Plan says  use of this device as a stand-alone 
procedure has not been shown to be safe and effective in long term studies. 
 
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 Minuteman procedure. Our 
reviewer says that the requested Minuteman procedure is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested procedure is intended for use with bone graft material 
and is not intended for stand-alone use. The reviewer found that current evidence-based medical guidelines and 
peer-reviewed literature do not fully support the interspinous fusion device procedure over the gold standard of lumbar fusion. Therefore, the reviewer found that the requested Minuteman procedure is not medically 
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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Minuteman procedure.