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

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99222) 
rendered on April 13, 2023. 
 
You asked the Plan to pay for the services. You say that medical records were sent for review. The Plan denied 
your request. The Plan says the documents do not support this level of care. 
 
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 99222 is "Initial 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 moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 55 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 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 documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level, or that 55 
minutes were spent. 
 
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 evaluation and management services (procedure code 99222) rendered on April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathogen testing provided on March 21, 2023, billed with 
13 units of code 87798. 
 
You asked the Plan to pay for the testing as billed. You say that this testing was medically necessary.  The Plan 
denied your request. The Plan says all codes were paid aside from the 13 units of 87798. The records do not 
support 13 other pathogens were tested to support the number of units.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 13 units of CPT code 87798 are not supported in the medical record. The medical record only 
supports 9 units of CPT code 87798. Based on this information, we decided that Medicare rules for coverage of 
the testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
pathogen testing provided on March 21, 2023, billed with 13 units of code 87798.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower extremity revascularization procedure (37221, 
37224, 37225, 37226, 37227, 37228, 37229, 37230, and 37231). 
 
You asked the Plan to pre-approve the lower extremity revascularization procedure. You say that this 
procedure is medically necessary. The Plan denied your request. The Plan says there is no evidence of 
atherosclerosis. 
 
The Plan follows Medicare rules. Medicare rules say that this procedure may be covered for the treatment of 
atherosclerotic obstructive lesions in the lower extremities.  
 
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 lower extremity revascularization 
procedure. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
documentation indicates that it is believed that the symptoms are more numbness than claudication with 
peripheral neuropathy being more the cause of symptoms. This is consistent with the objective data 
documenting palpable pedal pulses and normal arterial duplex without evidence of disease. There is no 
suggestion of limb threat. In the absence of an indication or evidence of lower extremity arteries arterial 
occlusive disease, this procedure is not medically necessary at this time. 
 
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 lower extremity revascularization procedure have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the lower extremity revascularization procedure (37221, 
37224, 37225, 37226, 37227, 37228, 37229, 37230, and 37231).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from February 21, 2023, to 
February 23, 2023. 
 
You asked the Plan to pay for the medication. You say that the medication should be covered. 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 pay for self-administered drugs provided 
from February 21, 2023, to February 23, 2023.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the aide services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found that the documentation does not support that you require additional skilled nursing services or skilled rehabilitation 
services to provide treatment that is medically necessary. You are medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations.  
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 36656 rendered on October 8, 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 that 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 36556 is "Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older." 
 
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 documentation supports that 
the services in question were rendered and appropriately coded. There is satisfactory documentation that a 
central line was placed in the internal jugular vein. There is satisfactory documentation that the line was placed 
centrally to 20 cm from the insertion site. As most central lines placed in the intensive care unit (ICU) are not 
placed under fluoroscopic guidance, the exact location of the tip cannot be documented, and it is not reasonable 
to require this information to justify billing.  
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 36656 rendered on October 8, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on April 12, 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 Current Procedural Terminology (CPT) code 99152-59 (1 Unit ) remains 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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older."  
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 medical record describes a 
colonoscopy with moderate conscious sedation was performed. In this case, CPT 99152 is an inappropriate 
code to report, as there is a more specific code that should 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99152) rendered on April 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 27, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says this provider is out-of-network and authorization was not 
obtained. 
 
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 an office visit provided on September 27, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) rendered on 
January 18, 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 code G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the laboratory report does not 
support that testing of twenty two or more drug classes was completed. 
 
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 drug testing services (procedure code G0483) rendered on January 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 71046, Q0092, and R0075 rendered on 
February 28, 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 71046: 
 
Radiologic examination, chest; 2 views  
Healthcare Common Procedure Coding System (HCPCS) Q0092: 
 
Set-up portable x-ray equipment 
 
HCPCS R0070: 
 
Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or 
location, more than one patient seen 
 
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 records only show that a one 
view chest x-ray was done. There was no documentation of the transportation and set-up of the portable x-ray 
equipment. 
 
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 71046, Q0092, and R0075 rendered on February 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of anesthetic agent and/or steroid into knee 
nerve branch using imaging guidance (64454). 
 
You asked the Plan to pre-approve injection of anesthetic agent and/or steroid into knee nerve branch using 
imaging guidance. You say that the enrollee is in extreme pain and needs this procedure. The Plan denied your 
request. The Plan says the request is not medically necessary because based on the medical literature this 
procedure is considered experimental or investigational and has not been proven to be beneficial for the 
enrollee's condition. 
 
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 injection of anesthetic agent and/or 
steroid into knee nerve branch using imaging guidance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that genicular 
nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the 
treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; 
osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; 
or as a treatment for individuals who are not candidates for knee replacement surgery. The review has 
determined that the requested genicular nerve block is considered experimental in nature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection of anesthetic agent and/or steroid into knee nerve branch using 
imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve 
injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance (64454).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 118 units of procedure code 01402 rendered on February 17, 
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 number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that this 
is incorrect coding. The base number of units for this is 7 units times the number of units, which would not be 
118 units.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for 118 units of procedure code 01402 rendered on February 17, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from June 20, 2023, to June 22, 
2023. 
 You asked the Plan to pay for the hospital services. You say that the enrollee was not on hospice during this 
period. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital services provided from June 20, 2023, to June 22, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Synergy Toric lens provided on April 20, 2023. 
 
You asked the Plan to pay for the Synergy Toric lens. You say that you had two exact same lenses put in your 
eyes. You say the lens placed on April 20, 2023, was denied while the other lens was approved.  The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the Synergy Toric 
lens provided on April 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has medical needs that 
exceed skilled nursing facility capabilities. You would like reconsideration based on the records submitted. The 
Plan denied your request. The Plan says the enrollee does not meet all the requirements for admission to an 
LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not already available 
and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for future outpatient rehabilitation services 
 
You asked the Plan to waive the copayments for future outpatient rehabilitation services. You say that you are 
requesting the Plan waive future copayments for therapy visits related to the long-term side effects of Covid-
19. The Plan denied your request. The Plan says the cost sharing will be applied according to the Plan contract. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for outpatient rehabilitation services.  
 
 
  You will be asked to pay a $30 copayment for each outpatient rehabilitation visit. This item/service falls within 
the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for 
future outpatient rehabilitation services