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

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
August 21, 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 Current Procedural Terminology (CPT) code 99223 (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 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." 
 
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 enrollee was treated on 
August 21, 2022. The provided record from that date shows a note with a focused history describing shortness 
of breath, occasional blood in stool, and severe anemia. The physical examination was brief and included only 
vital signs. The enrollee was treated with blood transfusion and monitoring with plans for colonoscopy the 
following day. The records insufficiently support a comprehensive history or examination and did not show 
sufficient support for medical decision-making of high complexity on 8/21/22. 
 
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 initial hospital care (procedure code 99223) rendered on August 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 billed for September 1, 2022. 
 
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 99215 is not supported by the medical records. 
 
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 99215 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 high level of medical decision making. When using time for code selection, 40-54 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 these services. Our reviewer says that procedure code 99215 
is not supported by the medical records. Our reviewer found the documented chief complaint is brief. There is 
no history of present illness and no complex decision making. The enrollee was there for a periodic infusion. 
The key elements indicating complex decision making are absent.  
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 99215 billed for September 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive surgical (MIS) fusion of the 
sacroiliac joint (SIJ). 
 
You asked the Plan to pre-approve MIS fusion of the SIJ. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules state that MIS fusion of the SIJ may be covered if certain 
criteria are met. 
 
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 MIS fusion of the SIJ. Our reviewer 
says that the enrollee does not meet criteria for this surgery. Our physician reviewer found there is no evidence 
of fracture, instability, or sacroiliac joint lesion. Sacroiliac joint fusion for degenerative pain is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MIS fusion of the SIJ have not been met. Therefore, we decided that the Plan 
does not have to pre-approve minimally invasive surgical (MIS) fusion of the sacroiliac joint (SIJ).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show a power wheelchair is appropriate. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that you have 4/5 strength in the upper extremities. You can adequately manage your mobility in the home. You do not 
require a power mobility device to perform ADLs in the home. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that a power scooter is medically necessary. The 
Plan denied your request. The Plan says that the requested scooter is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that you can walk more than household 
distances. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve Prednisone. You say that the enrollee has chronic back pain. 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 Prednisone.  Benefits for Prednisone 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
August 31, 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 Current Procedural Terminology (CPT) code 99223 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 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." 
 
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 documented history from 
August 31, 2022 describes the enrollee with a history of dementia and report of right leg flaccidity. However, 
the enrollee was not able to provide an adequate history. The physical examination was brief and focused. The 
records do not sufficiently support a comprehensive history or physical, nor was there support for 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (84443 and 84439) provided on 
November 22, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Review of the file shows 
that the claim was billed with diagnosis codes Z51.12, C43.71, and C77.4. The procedure code is not payable 
with the diagnosis codes billed. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (84443 and 84439) provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation therapy. 
 
You asked the Plan to pay for the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says Original Medicare is responsible for all Medicare-covered non-hospice services. 
 
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 radiation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site 
tooth #'s 7 and 9 (D7953), and therapeutic parenteral drug, single administration (D9610) provided on February 
15, 2023. 
 
You asked the Plan to pay for the bone replacement graft and a therapeutic parenteral drug. You say that you 
have been paying $9.00 premium for dental monthly. You also say that if would have been a covered service 
the Plan would have paid $560.00. The Plan denied your request. The Plan says these services are not covered 
under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation - per site tooth #'s 7 and 9 (D7953), and therapeutic parenteral drug, 
single administration (D9610) provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), 
intraoral - periapical each additional radiographic image (D0230) x2, biologic materials to aid in soft and 
osseous tissue regeneration, per site (D4265) and autogenous connective tissue graft procedure (including 
donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft (D4273) x3 
provided on November 16, 2022. 
 
You asked the Plan to pay for dental services. You say that you say that the services should be approved 
because they are necessary for your care plan. The Plan denied your request. The Plan says these services are 
not covered under your Plan. 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. D0220, D0230, D4265 and 
D4273 are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0220, D0230 x2, 
D4265 and D4273 x3 are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay dental services provided on November 16, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you have been seeing this 
provider since 2019 and it will better serve you to have continuity of care. The Plan denied your request. The 
Plan says the services you need are available to be provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office services to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0220) provided on 
December 22, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were given incorrect information and you 
believe you had available dental benefits. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of June 1, 2022. 
Therefore, we decided that the Plan does not have to pay for the intraoral radiographic image (D0220) provided 
on December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Orthopedic consultation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an Orthopedic consultation to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an Orthopedic consultation to be provided by an out-of-network (OON) provider.
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 you are requesting an expedited 
reconsideration stating the enrollee exceeds the established defining criteria for a medically appropriate 
LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for 
care in 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 available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cerebral perfusion analysis using computed tomography 
with contrast administration, including post-processing of parametric maps with determination of cerebral 
blood flow, cerebral blood volume, and mean transit time (0042T). 
 
You asked the Plan to pre-approve cerebral perfusion analysis. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says this procedure is covered if you are currently having a 
stroke. 
 
The Plan follows Medicare rules. Medicare rules say that computed tomography perfusion (CTP) is medically 
reasonable and necessary in patients with acute ischemic stroke (AIS) caused by unilateral large vessel 
occlusion (LVO) in the proximal anterior circulation evaluated at stroke centers. 
 
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 cerebral perfusion analysis. Our 
reviewer says that the requested cerebral perfusion analysis is not medically necessary. Our physician reviewer 
found the provided documentation indicates the enrollee is being electively referred for the study. The 
guidelines indicate that this service is only covered when performed on an emergent basis for a patient with acute ischemic stroke (AIS). As the services is not being provided in the setting of AIS or when computed 
tomography perfusion (CTP) would be used to guide acute treatment decisions, this service would not be 
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 cerebral perfusion analysis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve cerebral perfusion analysis using computed tomography with contrast 
administration, including post-processing of parametric maps with determination of cerebral blood flow, 
cerebral blood volume, and mean transit time (0042T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 81479 for date of 
service October 31, 2022. 
 You asked the Plan to pay for the laboratory services billed with code 81479. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
billed with code 81479 have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services billed with code 81479 for date of service October 31, 2022.