Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation device used for cancer treatment 
(E0766) provided from October 26, 2022, to December 26, 2022. 
 
You asked the Plan to pay for the device. You say that this device helps cancer cells from dividing, and you 
believe it is the reason why you are doing so well.  The Plan denied your request. The Plan says the enrollee 
has not been diagnosed with glioblastoma multiforme and does not meet the medical necessity criteria.  
 
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 device. Our physician reviewer found 
tumor treatment field therapy (Optune) is Food and Drug Administration (FDA) approved for use in 
combination with pemetrexed plus platinum-based chemotherapy for the first-line treatment of patients with 
unresectable, locally advanced, or metastatic malignant pleural mesothelioma (MPM). However, you 
completed cisplatin and pemetrexed on June 14, 2022, and Optune was continued. Therefore, for the time 
period of October 26, 2022, to December 26, 2022, Optune was continued. The service was not reasonable or 
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 device have not been met. Therefore, we 
decided that the Plan does not have to pay for the electrical stimulation device used for cancer treatment 
(E0766) provided from October 26, 2022, to December 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97164 billed for date of service September 8, 
2022. 
 
You asked the Plan to pay for procedure code 97164. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 97164 is bundled into payment for code G0283. 
 
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 97164 
is a column II code to column I code G0283. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 97164 billed for date of service September 8, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950-teeth # 4, 18, 29) and dental 
implant services (D6010, D6057, D6060). 
 
You asked the Plan to pre-approve core buildup (D2950-teeth # 4, 18, 29) and implant services  
(D6010, D6057, D6060). You say that you were never informed that implant services were not covered. The 
Plan denied your request. The Plan says the requested core buildup (D2950-teeth # 4, 18, 29) and implant 
services (D6010, D6057, D6060) are not a covered benefit. 
 
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 pre-approve core 
buildup (D2950-teeth # 4, 18, 29) and dental implant services (D6010, D6057, D6060).
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 the enrollee 
to get stronger so they can return home safely and be independent. The Plan denied your request. The Plan says 
the enrollee's needs can be met in 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 the enrollee does 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service December 24, 2022. 
 
You asked the Plan to pay for code 99233. You say that you billed with a payable diagnosis code. The Plan 
denied your request. The Plan says you billed this claim with an invalid pair of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the diagnosis code excluded should never be used at the same time as the code above the Excludes1 note.  
 
In this case, you billed this claim with the following diagnoses: R52, Z78.612, R10.9, I73.9, I10, E78.5 and  
T81.30XA. 
 
Code R52 has an Excludes1 relationship with code R10.9, which is why this claim has denied.  One of these 
diagnoses would need to be removed from the claim in order to conform with Excludes1 rules. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99233 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99233 billed for date of service December 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from August 9, 2022, to 
August 12, 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 this was not authorized. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval 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 pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
records indicate that the enrollee was stabilized and not in any immediate danger at the time of inpatient 
admission. The review has determined that the treating physician did not document (in the physician notes, on a 
form, or in an order) that the enrollee was not stable for transfer on any dates of service. After stabilization of 
the enrollee's clinical condition in the emergency department, the health plan should have been given the 
opportunity, in a timely manner, to transfer the enrollee to an in-network facility, and/or involve contracted 
providers in the care, and/or provide utilization management oversight to the enrollee. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services rendered from August 9, 2022, to August 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99223 billed for date of service January 26, 2023. 
 
You asked the Plan to pay for code 99223. You say that the medical records support payment for this code. The 
Plan denied your request. The Plan says that you billed an incorrect code.  The Plan says that because you 
billed Place of Service code 21, that you should have billed a different code for observation services. 
 
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 inpatient or observation care, per day, for the evaluation and management of a patient. 
 
We find that CPT code 99223 is supported in the medical record. Specifically, the Plans contention that a 
different code should have been used for observation services is not true.  Effective January 1, 2023, the 
definition of code 99223 changed.  Prior to January 1, 2023, it is true that there were separate codes used for 
inpatient visits versus observation care.  However, the coding change that occurred on January 1, 2023, 
effectively did away with the need to bill a different code for observation services.  Now, both inpatient and 
observation visits are billed using the same code.  Because these services were rendered after the date of this 
change, the billing of code 99223 with Place of Service code 21 is appropriate. Based on this information, we 
decided that Medicare rules for coverage of code 99223 have been met. Therefore, we decided that the Plan has 
to pay for code 99223 billed for date of service January 26, 2023.  
 
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 pay for procedure codes 20985, 27005, and 27066 rendered on 
November 4, 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 the records do not support the services 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 the denied codes is: 
 
CPT 20985: 
 
Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately 
in addition to code for primary procedure)  
CPT 27005: 
 
Tenotomy, hip flexor(s), open (separate procedure) 
 
CPT 27066: 
 
Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; deep 
(subfascial), includes autograft, when performed 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the use of modifier is not 
supported for any of these codes. In terms of CPT 20985, the computer assisted navigational procedure is a 
non-covered surgical service, and if used, is included under the existing code for the actual procedure 
performed. In terms of CPT 27995, the procedure was performed same anatomical location as the more 
comprehensive procedure, which in this case, would not be reported separately. In terms of CPT 27066, 
describes a bone cyst excision. However, there is a more comprehensive procedure - total hip arthroplasty - that 
was performed in the same location, which CPT 27066 would be inclusive to. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 20985, 27005, and 27066 rendered on November 4, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from July 28, 2022, to July 29, 
2022. 
 
You asked the Plan to pay for the medical services. You say that this claim was denied in error because the 
patient was not on hospice on the dates of service. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 8, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for medical services provided 
from July 28, 2022, to July 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you need help to regain function. The 
Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the submitted 
records do not support that skilled nursing services are required to effectively provide treatment, care, or 
services in order to improve your condition, or to establish a maintenance program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication (J3490) provided on November 29, 2022. 
 
You asked the Plan to pay for medication. You say that this is supported in the records. The Plan denied your 
request. The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for surgical 
procedures includes payment for the intra-operative services and supplies related to the surgery when furnished 
by the physician who performs the surgery. 
 
We looked at the file and Medicare rules. The record shows that the mediation at issue was an intra-operative 
supply for the radiofrequency ablation procedure performed on the same day. Based on this information, we 
decided that Medicare rules for coverage of medication have not been met. Therefore, we decided that the Plan 
does not have to pay for medication (J3490) provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 23, 2023. 
 
You asked the Plan to pay for an office visit.. You say that this should be covered. The Plan denied your 
request. The Plan says this was provided by a provider who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on January 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
June 30, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR panel was not billed as a single 
unit of service. 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 urine polymerase chain reaction 
(PCR) panel rendered on June 30, 2022.
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 enrollee inpatient rehabilitation set up to prepare 
for use with prosthetic leg. The Plan denied your request. The Plan says an intensive rehabilitation program is 
not medically necessary. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Favorable

 
We decided that the Plan has to hold you harmless for the general health panels (code 80050) you received 
from a network lab on April 22, 2022, and August 16, 2022. 
 
You asked the Plan to hold you harmless for the general health panels. You say that these lab services have 
been covered in the past. The Plan denied your request. The Plan says that these lab services aren't covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the general health panels by a contract provider. The file does not show that the Plan 
provided notice that the general health panels would not be covered. Under Medicare rules, this means the 
general health panels are considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for the general health panels (code 80050) you received from a network lab on April 22, 2022, and 
August 16, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies billed with code A4258 for date of service 
November 21, 2022. 
 
You asked the Plan to pay for code A4258. You say that you have provided documentation to support payment 
for this item. The Plan denied your request. The Plan says this billing exceeds the units allowable for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that  more than one spring powered device (code 
A4258) per 6 months is not reasonable and necessary.  In this case, the patient already received code A4258 on 
June 14, 2022.  As a result, coverage for code A4258 would not be available until at least six month had 
elapsed from this previous date of service.  That six-month period would extend to December 14, 2022.  You 
supplied the item in dispute a month prior to the allowable timeframe. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code A4258 have not been met. Therefore, we decided that the Plan does not have to pay for 
diabetic supplies billed with code A4258 for date of service November 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (64719, 26540, 26437, 64718) provided 
on November 3, 2022. 
 
You asked the Plan to pay for the medical services. You say that it was medically necessary to have the 
surgical assistant for this procedure and you would like the records reviewed and the clam reprocessed. The 
Plan denied your request. The Plan says Current Procedural Terminology (CPT) codes 26437 and 64719 have 
an assistant at surgery status indicator of 1 and 26540 and 64718 has an assistant at surgery status of 0. The 
Plan states that codes with an assistant surgery indicator of 0 are covered with supporting documentation to 
establish medical necessity.  
 
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 medical services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found both codes do not require an assistant surgeon. Ulnar collateral ligament (UCL) repair and 
neurolysis may be safely performed with an individual surgeon. These are routine simple procedures that do 
not require an assistant surgeon 
 
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 medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services (64719, 26540, 26437, 64718) provided on November 3, 2022.