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

 
We decided that the Plan does not have to pay for the services provided on May 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on July 21, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a face down chair (E1399). 
 
You asked the Plan to pre-approve a face down chair. You say that the requested chair is medically necessary. 
The Plan denied your request. The Plan says a face down chair is considered not reasonable and necessary 
since it is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a face down chair (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement batteries for a power wheelchair. 
 
You asked the Plan to pre-approve replacement batteries. You say that you have moved since getting your 
power wheelchair. You also say that you cannot use your power wheelchair in your new home. The Plan 
denied your request. The Plan says you have a manual wheelchair for use in your home. The Plan says this is 
the primary piece of mobility equipment. The Plan also says replacement batteries for a power wheelchair used 
outside the home are not covered. 
 
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 pre-approve replacement batteries for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture and mandibular complete 
denture. 
 
You asked the Plan to pre-approve the dental services. You say that dentures are a covered benefit. The Plan 
denied your request. The Plan says these services are not covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary complete denture and mandibular complete denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit identified with code 99211 for date of service 
August 23, 2022. 
 
You asked the Plan to pay for code 99211. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as 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 99211 is office or other outpatient visit for the evaluation 
and management of an established patient that may not require the presence of a physician or other qualified 
health care professional. 
 
We find that CPT code 99211 is not supported in the medical record. Specifically, this code has a status 
indicator of B. This means this code is a non-allowed item or service for OPPS when submitted on an 
outpatient hospital Part B bill type. This means this code is not payable as billed. Based on this information, we 
decided that Medicare rules for coverage of code 99211 have not been met. Therefore, we decided that the Plan 
does not have to pay for the office visit identified with code 99211 for date of service August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9348 billed for date of service November 
23, 2022 to November 29, 2022. 
 
You asked the Plan to pay for procedure code S9348. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9348 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9348 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9348 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9348 billed for date of service November 23, 2022 to November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service February 25, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on November 17, 
2022. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that code G0463 was billed on the same date as code 74177, which has a status indicator of S. Code 
G0463 was not billed with a modifier as required. As such, the claim was returned to provider (RTP). We also 
find that code G1004 is not paid by Medicare when submitted on an outpatient claim. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the outpatient hospital services provided on November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1852) and suspension sleeve (L2397) 
provided December 9, 2022. 
 
You asked the Plan to pay for the orthoses. You say that you have attached supporting documentation. please 
reprocess the claim. The Plan denied your request. The Plan says the documentation submitted did not 
sufficiently support the billed supply code. 
 
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 orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a past medical history that includes knee osteoarthritis who was prescribed a 
knee orthosis for the treatment of their medical condition. The documentation indicates the enrollee was seen 
by their medical provider on November 7, 2022, for a general follow-up. The physical exam showed knee 
crepitus and that the enrollee walked with a cane with a stable gait. There was no joint laxity. In this case, the 
enrollee has not had recent surgery or a recent injury. The documentation does not support that the joint is 
unstable or that there is joint laxity. The requested knee orthosis 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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for knee orthosis (L1852) and suspension sleeve (L2397) provided December 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve roflumilast. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. 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 roflumilast.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 for date of service November 11, 
2022. 
 
You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99284 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate 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 presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function. 
 
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 procedure code 99284. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the documentation did not support medical 
decision making of moderate complexity. Therefore, code 99284 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99284 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99284 for date of service November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 5 treatments of radiation management (77427) provided by 
an out-of-network (OON) provider on December 13, 2022, through December 18, 2022. 
 
You asked the Plan to pay for the 5 treatments of radiation management. You say that you obtained 
authorization for the services which was valid from November 29, 2022, through February 27, 2023. The Plan 
denied your request. The Plan says the services were provided out-of-network without prior authorization. The 
Plan says that the prior authorization you are referring to was for a different code/service. 
 
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. The authorization number referenced (ending in 5626) was issued for code 77386. We 
found no exception that would require the Plan to pay for the radiation management services provided OON 
and billed with code 77427. Therefore, we decided that the Plan does not have to pay for 5 treatments of 
radiation management (77427) provided by an out-of-network (OON) provider on December 13, 2022, through 
December 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99239 for date of service July 
10, 2021, to July 11, 2021. 
 
You asked the Plan to pay for procedure codes 99223 and 99239. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the codes billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 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. 
 
The CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes 
 
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 procedure codes 99223 and 99239. Our reviewer says that 
the documentation does not support the codes billed. Our reviewer found the enrollee was admitted after a fall 
with a left hip fracture. The documentation submitted does not support medical decision making of high 
complexity; therefore, code 99223 is not supported. The submitted discharge summary did not support hospital 
discharge day management of more than 30 minutes was performed; therefore, code 99239 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99223 and 99239 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99223 and 99239 for date of service July 10, 2021, to 
July 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services denied with denial code G, 
rendered from March 26, 2022, through April 18, 2022. 
 
You asked the Plan to pay for inpatient hospital services denied on the Plans Itemized Bill Determination with 
denial codes. You say that you are appealing the recoupment of the partially adjustment claim payment. The 
Plan denied your request. The Plan says several items and services initially denied due to not having an 
itemized bill have now been identified as routine items and services. The Plan states they are continuing to 
uphold the denial of the routine items and services billed with denial code G". 
 
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 inpatient hospital services denied on the Plans Itemized Bill Determination with denial codes. Our physician reviewer found the documentation 
submitted was reviewed and does not meet criteria. Review of the denied multiple services totaling $17,964.50, 
which denied correctly as these charges fall under "room and board" charges and would not be separately 
reported. Denied charges fall into monitoring equipment/supplies and nursing care, which are bundled into 
"room and board" charges. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services denied on the Plans Itemized Bill Determination 
with denial codes have not been met. Therefore, we decided that the Plan does not have to pay for inpatient 
hospital services denied with denial code G, rendered from March 26, 2022, through April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA for the SI joint. You say that pain killers no longer help with the 
enrollee's pain. You say that they have tried multiple injections for the enrollee's pain. You also say that the 
enrollee is having a hard time walking and sleeping due to the pain. The Plan denied your request. The Plan 
says the requested injection 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 RFA for the SI joint. Our reviewer says 
that the requested RFA for the SI joint is not considered medically reasonable and necessary in this case. Our 
physician reviewer found studies completed say that this procedure does not improve outcomes compared to standard treatment of SIJ pain. Radiofrequency ablation for denervation, whether performed using traditional, 
cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary. 
Therefore, the reviewer found that the requested SI joint RFA 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 RFA for the SI joint have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA) for the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation. 
 
You asked the Plan to pre-approve genicular nerve ablation. You say that genicular nerve ablation is medically 
necessary. The Plan denied your request. The Plan says the requested genicular nerve ablation is considered 
investigational and not medically necessary for the treatment of chronic knee pain. 
 
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 nerve ablation. Our reviewer 
says that the requested genicular nerve ablation is not considered medically reasonable and necessary. Our 
physician reviewer found that this is considered an experimental/investigational procedure and 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 nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve ablation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 2, 2022, to 
March 3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 2, 2022, to 
March 3, 2022.