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

 
We decided that the Plan does not have to pay for code 99214 billed for date of service January 25, 2023. 
 
You asked the Plan to pay for code 99214. You say that this service was medically necessary. The Plan denied 
your request. The Plan says code 99214 is not supported by the medical record. The records don't support a 
moderate level of decision making or the total time required of the code 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 99214 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 3039 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 code 99214. Our reviewer says that code 99214 is not 
supported by the medical record. Our reviewer found the medical records show that this enrollee presented for 
follow-up of an opioid use disorder. While the documentation supports an appropriate exam, it does not support 
an appropriate history or medical decision making of moderate level. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99214 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99214 billed for date of service January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam CT capture and interpretation with field of 
view of both jaws; with or without cranium (D0367), bone replacement graft  retained natural tooth  first site 
in quadrant, tooth #31 (D4263) and guided tissue regeneration, natural teeth  resorbable barrier, per site, tooth 
#31 (D4266). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says D4263 and D4266 are to correct defects around natural teeth. The Plan 
states that the x-ray your dentist submitted shows that tooth number 31 is not present.  
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our physician 
reviewer found D4266, is for natural teeth, and you do not have tooth #31 as noted. This procedure code would 
not be applicable for an area in the mouth where there is not a natural tooth present. D4263 is bone replacement 
first site in the quadrant and does not note that it must be in an area where there is a natural tooth. A pano x-ray 
dated July 10, 2023, was included and reviewed. The x-ray is blurry, and this type of x-ray does not adequately 
show the bone level in #31. There is not enough information, and based off the clinical documentation 
reviewed, D0367, D4263, and D4266 are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cone beam CT capture and interpretation with field of view of both jaws; with or 
without cranium (D0367), bone replacement graft  retained natural tooth  first site in quadrant, tooth #31 
(D4263) and guided tissue regeneration, natural teeth  resorbable barrier, per site, tooth #31 (D4266).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block (64454). 
 
You asked the Plan to pre-approve the service. You say that the enrollee cannot go in for surgery. You state 
that the enrollee had a nerve block done a few months back and it helped. You state the enrollee wants to have 
it done again. The Plan denied your request. The Plan says this 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/ investigational procedure. There is an ongoing clinical trial 
of patients with prior total knee pain; 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the genicular nerve block (64454).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for replacement of gastrostomy provided on February 14, 2023. 
 
You asked the Plan to pay for replacement of gastrostomy. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for replacement of 
gastrostomy provided on February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on May 2, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on May 2, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (EM) services and 
electrocardiogram (ECG) provided on February 15, 2023, billed with codes 99284 and 93010.  
 
You asked the Plan to pay for the EM services and ECG as billed. You say that these services should be paid. 
The Plan denied your request. The Plan says the services at issue were not billed correctly.  
 
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 93010 is Column 2 code in relation to Column 1 code 12002, which 
was billed by the same provider on the same date of service. Code 93010 was not billed with a modifier to 
bypass the edit. As such, the Medicare billing rules for this service have not been met.  
 
In regard to code 99284, the service was provided on the same date as code 12002, which has a global surgery 
period of 000. As this EM service was provided on the same date, it must be billed with a modifier to indicate 
that it is separately payable. Since this was not billed with a modifier, it cannot be separately paid.  
 
Based on this information, we decided that Medicare rules for coverage of the EM services and ECG as billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and 
management (EM) services and electrocardiogram (ECG) provided on February 15, 2023, billed with codes 
99284 and 93010.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that without the requested service, the enrollees 
balance is affected and could result in a fall or further damage her hip or leg. 
 The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of an Optimizer Smart device (0408T). 
 
You asked the Plan to pre-approve implantation of an Optimizer Smart device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 implantation of an Optimizer Smart 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, 
cardiac contractility modulation (CCM) remains the subject of multiple studies examining long-term efficacy, 
as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, 
the CCM system is not considered to be medically necessary in 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 implantation of an Optimizer Smart device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of an Optimizer Smart device (0408T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 14, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the patient received these services, so this claim 
should be paid. The Plan denied your request. The Plan says these services were not billed correctly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 14, 2023.
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 has a serious, life-threatening 
constellation of acute medical problems that have left her at a functional status below her baseline. The Plan 
denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not 
meet the requirements for approval. 
 
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 an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 procedure code 99233 billed for  
 
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 procedure code 99233 is 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 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 
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 these services. Our reviewer says that  Our reviewer found the submitted records do not support high level of medical decision making or the total time required for code 
99233. The records show that a comprehensive history and a comprehensive exam were performed but not 
medical 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99233 billed for
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70552 billed for date of service April 18, 
2023. 
 You asked the Plan to pay for procedure code 70552. You say that you do not believe code 70552 should be 
bundled with any other code. The Plan denied your request. The Plan says payment for code 70552 is bundled 
into payment for code 70553. 
 
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 70552 
is a column II code to column I code 70553. 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 70552 billed for date of service April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service March 9, 
2023. 
 
You asked the Plan to pay for procedure code 36000. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 36000 is considered bundled and not separately 
payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service March 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 27, 2023. 
 
You asked the Plan to pay for the medical services. You say that the diagnosis codes billed are payable. 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 J96.01 has an Excludes1 note in relation to R06.00. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the medical services have not been met. Therefore, we decided that the Plan does not have to 
pay for medical services provided on March 27, 2023.
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 currently meets acute inpatient 
rehabilitation admission criteria under CMS guidelines. The Plan denied your request. The Plan says the 
inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for approval. 
 
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 an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 21, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on March 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Kodiak ice machine and compression device purchased 
on May 4, 2023. 
 
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 provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the items at issue were purchased from a provider 
that is not Medicare-certified. Therefore, we decided that the Plan does not have to pay for the Kodiak ice 
machine and compression device purchased on May 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service February 17, 
2023.  
 
You asked the Plan to pay for procedure code 99232. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 99233. 
 
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 99232 is a column II code to column I code 99233 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99232 billed for date of service February 17, 2023.