Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mobile imaging services provided on March 22, 2023. 
 
You asked the Plan to pay for the mobile imaging services. You say that these services were medically 
necessary and should not be considered incidental to any other service. The Plan denied your request. The Plan 
says you billed an incorrect Place of Service code on the claim. The place of service 11 was billed, however, 
documentation received does not support the services were performed in an office or other outpatient setting 
but rather in a mobile setting at a skilled nursing facility (SNF). There is a more appropriate place of service 
code (POS 15). 
 
The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, 
they are often provided to serve an entity for which another Place of Service (POS) code exists. In those cases, 
providers should use the POS code for that entity. However, if the mobile unit is not serving an entity which could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15. 
 
In this case, you billed POS code 11 (which indicates an office setting).  These mobile x-ray services did not 
occur in an office setting, but rather in a mobile unit in the parking lot of a skilled nursing facility.  As a result, 
this claim should have been billed with either the SNF POS (31) or the mobile unit POS (15). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the mobile imaging services have not been met. Therefore, we decided that the Plan does not have 
to pay for mobile imaging services provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20610 and 99214 rendered on February 23, 
2023.  
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 20610: 
 
Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); 
without ultrasound guidance 
 
CPT 99214: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. When using 
time for code selection, 30-39 minutes of total time is spent on the date of the encounter 
 
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 provider reported CPT 20610 
with modifier 50, bilateral procedure, and two units. However, the additional units cannot be verified in the 
medical records. Additionally, CPT 99214 was reported with modifier 25. The evaluation and management 
service was not significant and separately identifiable, as it was done for bilateral knee pain following the 
procedure performed on the knees. 
 
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 20610 and 99214 rendered on February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 2, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on May 2, 2023, by an 
OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant-at-surgery services provided during a spinal 
procedure on March 9, 2023.  
 
You asked the Plan to pay for the surgical assistant services. You say that this is billed correctly and should be 
paid. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported 
together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that M43.00 has an Excludes1 note in relation to M43.16. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the surgical assistant services have not been met. Therefore, we decided that the Plan does not 
have to pay for the assistant-at-surgery services provided during a spinal procedure on March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments provided from January 9, 2023, 
to February 14, 2023. 
 
You asked the Plan to pay for the acupuncture treatments. You say that you suffer from neck pain and the Plan 
informed you that acupuncture was a covered benefit. The Plan denied your request. The Plan says acupuncture 
is only covered to treat CLBP. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services at issue would not be used to treat CLBP. 
Therefore, we decided that the Plan does not have to pay for the acupuncture treatments provided from January 
9, 2023, to February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan follows Medicare rules. The rules state 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 (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) (77373). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no good evidence that this treatment is safe and effective. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the  provided documents include only an SBRT plan treating a lesion in the right side of the spine 
(presumably adrenalectomy bed) to a total dose of 35Gy in 5 fractions. There is not enough information to 
consider this request 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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve stereotactic body radiation therapy (SBRT) (77373).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the services. You say that it is imperative that the provider be able to use the 
image guidance radiation therapy to treat the enrollee's cancer. The Plan denied your request. The Plan says 
there is not enough evidence that this type of radiation therapy guidance is needed or effective for your skin 
cancer. Therefore, it not considered standard of care. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that due to limited available good quality data, the decision to use US-IGRT is still a clinical equipoise. 
Therefore, US-IGRT is not considered a medical necessity for this 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 pre-approve ultrasound guided radiation therapy (IGRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and intraoral - 
complete series of radiographic images (D0210) provided on May 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation was exhausted on date of service May 5, 2022. Your 
benefit for the intraoral - complete series of radiographic images was exhausted on November 12, 2019. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and 
intraoral - complete series of radiographic images (D0210) provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on October 19, 2022, to 
December 16, 2022. 
 
You asked the Plan to pay for chiropractic services. You say that it is medically necessary. The Plan denied 
your request. The Plan says this service is excluded from Medicare coverage. 
 
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 chiropractic services provided on October 19, 2022, to December 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) provided on May 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are on a fixed income and were informed 
by the provider that all procedures would be covered. The Plan denied your request. The Plan says this service 
is not a covered benefit under your dental plan. 
 
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 the core 
buildup (D2950) provided on May 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q9967 rendered on December 20, 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 code Q9967 is "Low osmolar contrast material, 300-399 
mg/ml iodine concentration, per ml." 
 
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 provider reported National 
Drug Code (NDC) number 00270131535; however, this number does not support the contrast documented and therefore cannot be verified. 
 
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 code Q9967 rendered on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.  
 You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that hyperbaric oxygen therapy is 
medically necessary. The Plan denied your request. The Plan says hyperbaric oxygen therapy is not a covered 
for the diagnosis of neurodegenerative brain disease and sphingolipidosis. 
 
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy is covered when the 
criteria listed in the Medicare rules section of this decision are met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve hyperbaric oxygen therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this device is considered 
medically necessary.  The Plan denied your request. The Plan says this device is not covered. 
 
The Plan follows Medicare rules. The rules state 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 (E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air fluidized bed and trapeze bar (E0194x13 and 
E0940 x13) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an air fluidized bed and trapeze bar to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an air fluidized bed and trapeze bar (E0194x13 and E0940 x13) to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial evaluation and management (EM) services provided on 
March 10, 2023, billed with code 99222. 
 
You asked the Plan to pay for the EM services. You say that the services were medically necessary.  The Plan 
denied your request. The Plan says that the Place of Service (POS) code 23 should not be billed with code 
99222. 
 
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. We find that the Plan's rationale is not appropriate in this case. While the POS 
code 23 would usually be billed with emergency department codes, the rules do not appear to disallow an 
outpatient observation code to be reported in this scenario. Both POS codes indicate payment of the facility rate 
on the Physician Fee Schedule. In this case, the records support that the enrollee was in the emergency room at 
the time of the services and was admitted the same day to outpatient observation. As such, both the procedure 
code and the POS code are supported.  Therefore, we decided that the Plan has to pay for the initial evaluation 
and management (EM) services provided on March 10, 2023, billed with code 99222.  
 
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 evaluation and management (EM) services provided on March 10, 
2023. 
 
You asked the Plan to pay for the EM services. You say that these were two specialists treating the enrollee for 
different aspects of their condition. The Plan denied your request. The Plan says that the two providers at issue 
are both Internal Medicine specialist, meaning they cannot both be paid for EM services on the same date.  
 
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. We find that the Plan's denial rationale in this case is not supported. While the 
two physicians noted by the Plan have the same taxonomy associated with their National Provider 
Identification (NPI) numbers, the provider at issue in this case is documented in the records to be working for 
Infectious Disease, while the other was working for general medicine. As these two providers were not 
working as the same specialty on this date of service, they can both be paid for the EM services provided.  
Therefore, we decided that the Plan has to pay for the evaluation and management (EM) services provided on 
March 10, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that genicular artery embolization is 
medically necessary. The Plan denied your request. The Plan says the documentation given to us does not show 
that this procedure is being requested for uncontrolled bleeding. 
 
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 genicular artery embolization. Our 
reviewer says that the requested genicular artery embolization is not considered medically reasonable and 
necessary. Our physician reviewer found that genicular artery embolization is considered experimental/ 
investigational for treatment of pain of knee osteoarthritis. It is the subject of ongoing clinical trials. 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.