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

 
We decided that the Plan does not have to pay for the platelet rich plasma (PRP) (P9020) and lidocaine infusion 
(J2001) provided on January 3, 2023. 
 
You asked the Plan to pay for the PRP and lidocaine injections. You say that you were not able to receive 
physical therapy in Michigan as the appointment time was in January when you would be in Florida. You say 
that you have been treated by your regular doctor and had vascular testing done within the last six months. You 
also say that this should be treated as a specialist visit and only have a $50 copayment. The Plan denied your request. The Plan says the PRP is considered experimental and investigational. The Plan also says that the 
lidocaine infusion 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 pay for the PRP and lidocaine injections. Our 
reviewer says that the PRP and lidocaine injections are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the guidelines indicate that the evidence is insufficient to determine the 
effects of PRP on health outcomes for knee osteoarthritis. The reviewer found that it is strongly recommended 
to not use PRP injections for knee arthritis. The reviewer also found that the current peer-reviewed medical 
literature and the Medicare-approved major drug compendia provide no support for the use of lidocaine for 
myofascial trigger point injections for knee pain. Therefore, the reviewer found that the PRP and lidocaine 
injections are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PRP and lidocaine injections have not been met. Therefore, we decided that 
the Plan does not have to pay for the platelet rich plasma (PRP) (P9020) and lidocaine infusion (J2001) 
provided on January 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 9, 2022, to 
February 10, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
inpatient admission should be paid at the DRG originally billed. The Plan denied your request. The Plan says 
although the diagnosis N17.0 (Acute kidney failure with tubular necrosis) is documented), reasonable clinical 
evidence within the health record is not present to clinically validate the diagnosis. As a result, a lower DRG 
was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis N17.0 (Acute kidney failure with tubular 
necrosis). 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that diagnosis N17.0 (Acute kidney failure with tubular necrosis) is 
not supported in the medical record. Our physician reviewer found the enrollee was hospitalized for a 
scheduled procedure.  The procedure was performed without complication and the enrollee was discharged 
after one midnight of care.  Upon arrival there was a mild elevation of her renal labs, likely secondary to being 
'nothing by mouth' (NPO) for the procedure, but no evidence of intrinsic/cellular renal failure, and no evidence 
that renal issues affected the course of the hospitalization.  As such, the billing of N17.0 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 9, 2022, to February 10, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96375 billed for date of service January 25, 
2023. 
 You asked the Plan to pay for procedure code 96375. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 96375 is bundled into payment for code 71275. 
 
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 96375 
is a column II code to column I code 71275. 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 96375 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 a crown (D2751) and partial dentures (D5213). 
 
You asked the Plan to pre-approve a crown and partial dentures. You say that you need these services because 
you are in pain and have trouble eating. The Plan denied your request. The Plan says these services are not 
covered. 
 
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 
crown (D2751) and partial dentures (D5213).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80324, 80346, 80348, 80353, 80354, 80355, 
80356, 80358, 80359, 80361, 80362, 80365, 80368, 80369 and 80371 billed for date of service January 5, 
2023. 
 
You asked the Plan to pay for procedure codes 80324, 80346, 80348, 80353, 80354, 80355, 80356, 80358, 
80359, 80361, 80362, 80365, 80368, 80369 and 80371. You say that these services were medically necessary and appropriate. The Plan denied your request. The Plan says the billed codes are 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 codes 80324, 80346, 80348, 80353, 80354, 80355, 80356, 80358, 80359, 80361, 
80362, 80365, 80368, 80369 and 80371 have a Status Indicator of I on the Physician Fee Schedule. This means 
that procedure codes 80324, 80346, 80348, 80353, 80354, 80355, 80356, 80358, 80359, 80361, 80362, 80365, 
80368, 80369 and 80371 are not valid for Medicare purposes. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 80324, 80346, 80348, 80353, 80354, 80355, 80356, 80358, 
80359, 80361, 80362, 80365, 80368, 80369 and 80371 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 80324, 80346, 80348, 80353, 80354, 80355, 80356, 80358, 80359, 
80361, 80362, 80365, 80368, 80369 and 80371 billed for date of service January 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has COPD, atrial fibrillation, coronary artery disease, severe obesity with a body-mass index 
(BMI) of 39, and a history of Ventricular fibrillation (V-fib) arrest. The enrollee was recently hospitalized with 
weakness, nausea and vomiting, and was felt to have pulmonary edema and COPD exacerbation. An arterial 
blood gas (ABG) was consistent with acute on chronic hypercarbic respiratory failure. There are no pulmonary 
function tests to assess the severity of the COPD. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. The enrollee may benefit from BiPAP with average volume-assured pressure 
support (AVAPS) during sleep as an outpatient. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrocentesis, aspiration and/or injection, major 
joint or bursa with ultrasound guidance (20611), and ultrasonic guidance (76942) provided on May 26, 2022.  
 
You asked the Plan to pre-approve the injection and ultrasonic guidance. You say that the services were 
medically necessary. You also say that procedure code 20611 was paid for other dates of service. The Plan 
denied your request. The Plan says the services are considered experimental and investigational and therefore 
are not covered. 
 
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 injection and ultrasonic guidance. 
Our reviewer says that the injection and ultrasonic guidance are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation indicates that the enrollee has 
had gel injections in the past. The reviewer found that the documentation does not indicate the degree of pain 
relief that was achieved. Therefore, the reviewer found that the injection and ultrasonic guidance are not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection and ultrasonic guidance have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the arthrocentesis, aspiration and/or injection, major joint or bursa 
with ultrasound guidance (20611), and ultrasonic guidance (76942) provided on May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator you purchased on 
November 28, 2022. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that you found a great deal online for 
the portable oxygen concentrator, which is why you purchased it.  You requested that this claim be reprocessed 
under your out-of-network benefit. The Plan denied your request. The Plan says purchased oxygen equipment 
is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. In this case, you purchased the oxygen 
equipment at issue.  Neither Medicare nor your Plan covers purchased oxygen equipment. Therefore, we 
decided that the Plan does not have to pay for the portable oxygen concentrator you purchased on November 
28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the destruction by neurolytic agent of the facet joint. 
 
You asked the Plan to pre-approve the destruction by neurolytic agent of the facet joint. You say that you need 
this procedure to help with pain. The Plan denied your request. The Plan says the medical criteria for the 
requested procedure 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 the destruction by neurolytic agent of 
the facet joint. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the criteria that must be met is 80% pain relief in each of 
2 sets of diagnostic blocks. Only one set was performed and only 70% was achieved; therefore, this procedure 
is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the destruction by neurolytic agent of the facet joint have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the destruction by neurolytic agent of the 
facet joint.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle fracture treatment (27786) provided on September 25, 
2022. 
 
You asked the Plan to pay for code 27786. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says only 1 splint was applied for both fractures. 
 
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 27786 is closed treatment of distal fibular fracture (lateral 
malleolus); without manipulation. 
 
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 27786. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found according to the National Correct Coding Institute (NCCI) policy manual, if a single cast, strapping, or splint treats multiple closed fractures without manipulation, only one 
closed fracture treatment without manipulation code may be reported. Procedure code 27762 was reported and 
approved; therefore code 27786 may not be reported. 
 
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 27786 have not been met. Therefore, we decided that the Plan does not 
have to pay for ankle fracture treatment (27786) provided on September 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
you. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that you have COPD and severe obesity. There are no pulmonary function tests to confirm airways obstruction and 
assess severity. An arterial blood gas done on May 10, 2023, was consistent with chronic CO2 retention. There 
is no diagnosis of thoracic restrictive disease or neuromuscular disease. You may benefit from BiPAP with 
average volume-assured pressure support (AVAPS) during sleep as an outpatient. This has not been tried and 
failed, according to the records provided. Medicare does not cover a home ventilator when used at settings that 
can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service November 25, 2022. 
 
You asked the Plan to pay for code 99285. You say that the patient had multiple exams on this date of service. 
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 items/services at issue were 
reimbursed by the Plan on January 13, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for code 99285 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 99285 billed for date of service November 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve ablation rendered on March 21, 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 services were 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the genicular nerve ablation is considered 
experimental/investigational in nature and is the subject of ongoing clinical trials. The enrollee is not enrolled in a clinical trial. The services were therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the genicular nerve ablation rendered on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97610 billed for date of service September 6, 
2022. 
 You asked the Plan to pay for procedure code 97610. You say that you have submitted medical records to 
support payment. The Plan denied your request. The Plan says payment for code 97610 is bundled into 
payment for code 11043. 
 
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 97610 
is a column II code to column I code 11043. 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 97610 billed for date of service September 6, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for infusion services identified with codes J7030, 96360, 96375, and 96377 
received November 1, 2022, to January 24, 2023. 
 
You asked the Plan to pay for infusion services identified with codes J7030, 96360, 96375, and 96377. You say 
that you disagree with the amounts owed. The Plan denied your request. The Plan says that payment is not 
allowed for this service because the procedure code billed is not recognized by Medicare. 
 
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. Review of the file shows that the case file contains conflicting information. The 
denial explanation provided by the Plan was for ambulance services. Ambulance services were not the services 
at issue. You, the enrollee received services from an out of network provider. The coinsurance shown on the 
submitted explanation of benefits and claim payments is not adequately supported by the documentation. The 
documentation does not contain explanation of why the coinsurance is owed and what the coinsurance is for. 
The documentation shows that you received the services from an in-network provider. This means the Plan did 
not substantiate their denial. Therefore, we decided that the Plan has to pay for infusion services identified with 
codes J7030, 96360, 96375, and 96377 received November 1, 2022, to January 24, 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 code 36000 billed for date of service February 2, 
2023. 
 You asked the Plan to pay for procedure code 36000. You say that this service is supported in the medical 
records. The Plan denied your request. The Plan says payment for code 36000 is bundled into payment for code 
37215. 
 
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 36000 
is a column II code to column I code 37215. 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 36000 billed for date of service February 2, 
2023.