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

 
We decided that the Plan has to pay for the services (93010, 93571, 99152) provided on January 13, 2023, and 
January 19, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed codes 
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 93010 is "Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only". The CPT 
Code Manual definition of code 93571 is "Intravascular Doppler velocity and/or pressure derived coronary 
flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically 
induced stress; initial vessel (List separately in addition to code for primary procedure)". 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 use of codes 93010, 
93571, and 99152 is supported by the records provided. Our reviewer found that the documentation supports 
that a 12-lead ECG was performed with interpretation, so code 93010 is supported. The documentation also 
supports that intravascular flow reserve study was performed during left heart catheterization with 45 minutes 
of sedation time, so codes 93571 and 99152 are 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 the services have been met. Therefore, we decided that the Plan has to pay for 
the services (93010, 93571, 99152) provided on January 13, 2023, and January 19, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A0425 and A0427 for date of service March 8, 2023. 
 
You asked the Plan to pay for codes A0425 and A0427. 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 certain diagnosis codes are not appropriate to be 
billed as the primary diagnosis.   
 
We looked at the file and Medicare rules. Review of the file shows that these services were billed with a 
primary diagnosis code B97.29 (Other coronavirus as the cause of diseases classified elsewhere). Per coding 
guidelines, bacterial agents, as the cause of diseases classified elsewhere, may be required to identify the 
bacterial organism causing the infection. A "use additional code" note will normally be found at the infectious 
disease code, indicating a need for the organism code to be added as a secondary code. This means code 
B97.29 is not acceptable as a primary diagnosis as billed. Based on this information, we decided that Medicare 
rules for coverage of codes A0425 and A0427 have not been met. Therefore, we decided that the Plan does not 
have to pay for codes A0425 and A0427 for date of service March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 50200 for date of service October 25, 2022. 
 
You asked the Plan to pay for procedure code 50200. 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 an anatomic modifier should be billed with 
specific codes.  
 
We looked at the file and Medicare rules. Review of the file shows that code 50200 was not billed with an 
appropriate modifier. Based on this information, we decided that Medicare rules for coverage of procedure 
code 50200 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
50200 for date of service October 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve ablation. 
 
You asked the Plan to pre-approve the nerve ablation. You say that the orthopedic surgeon diagnosed you with 
excessive arthrofibrosis following a noncompartmental knee replacement.  The Plan denied your request. The 
Plan says this procedure is experimental 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 the nerve ablation. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that 
shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to corroborate the safety/efficacy of the genicular nerve radiofrequency ablation procedure in the clinical setting of knee osteoarthritis. No compelling rationale is presented, or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 
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 nerve ablation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a genicular nerve ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223-
25) rendered on May 15, 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 99233-25 (1 units) 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 99233 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for 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 high level. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99223-25) rendered on May 15, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705-26 billed for date of service May 9, 
2023. 
 You asked the Plan to pay for procedure code 76705-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 76705-26 is bundled into 
payment for code 76981-26. 
 
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 
76705-26 is a column II code to column I code 76981-26. 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 76705-26 billed for date of service 
May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 62323 billed for date of service January 12, 
2023. 
 You asked the Plan to pay for procedure code 62323. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 62323 is bundled into payment for code 27097. 
 
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 62323 
is a column II code to column I code 27097. 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 62323 billed for date of service January 12, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires physical therapy to improve 
their strength, balance , gait, transfers, and overall mobility . The Plan denied your request. The Plan says an 
IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 50200 billed for date of service October 26, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the biopsy has nothing to do with interventional 
radiology. The Plan denied your request. The Plan says the service is bundled into the global surgery period for 
code 36558. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The records show that procedure code 36558, which has a 10-day global 
period, was provided on October 24, 2022. We find that CPT code 50200 was not billed with a modifier to 
indicate this service was not related to procedure code 36558. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 50200 billed for date of service October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the requested ventilator system will 
provide the enrollee the ventilatory support they require. The Plan denied your request. The Plan says a home 
ventilator is not medically necessary for this patient because their needs can be met with an alternative device 
such as a BiPAP device with average volume-assured pressure support (AVAPS).   
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has severe COPD, and the requested home ventilator system is not a true ventilator because is it not capable of 
providing full ventilatory support. Also, it is intended to be used during activities, and there is inadequate 
evidence that it is beneficial in the treatment of any chronic lung disease. Therefore, the requested home 
ventilator system 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 a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve ESI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee has not had 3 months of relief since the previous injection. 
 
The Plan follows Medicare rules. Medicare rules state that repeat ESI is only 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 ESI. Our reviewer says that the enrollee 
does not meet criteria for an ESI. Our physician reviewer found the documentation does not reveal at least 50% 
of sustained improvement in pain relief and/or improvement in function for at least 3 months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that you would like reconsideration because the requested 
foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
 
 
 
 
 
 
 Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code L1820-LT billed for date of service April 17, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the previous brace was the wrong size. The Plan 
denied your request. The Plan says the reason for replacement is not indicated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that CPT code L1820-LT is not supported in the medical record. Orthosis L1820-LT was previously 
provided on February 1, 2023. A replacement was not provided due to loss or irreparable damage. Replacement 
for other reasons is not covered. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
L1820-LT billed for date of service April 17, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 You asked the Plan to pre-approve the therapy services. You say that you still need physical therapy to recover 
from a recent fall and balance issues. The Plan denied your request. The Plan says the requested services are 
not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have previously been treated with outpatient therapies and should 
be independent with a home exercise program. There is no documentation of a recent injury or decline in 
function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition and therefore are 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy (PT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ESI. 
 
You asked the Plan to pre-approve the ESI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the criteria for coverage 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 ESI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the history, physical examination, and cervical imaging does not support specific objective 
support and evidence of radiculopathy in the proposed area for injection. There is no detailed neuromuscular 
exam of the upper extremities including strength, sensation, reflex testing. Therefore, the criteria for coverage 
have not been met. 
 
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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an ESI.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307 and G0483 billed for date of service 
March 7, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed codes 
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 80307 is presumptive drug testing. The definition of code 
G0483 is definitive drug testing of 22 or more drug classes. 
 
 We find that CPT codes 80307 and G0483 are not supported in the medical record. The records do not show 
that presumptive testing was provided. The records do not show that testing of 22 or more drug classes was 
needed based on medication side effects or inefficacy, suspicious behaviors, or other clinician documented 
change in affect or behavioral pattern. Based on this information, we decided that Medicare rules for coverage 
of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 80307 and G0483 billed for date of service March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are necessary. The Plan 
denied your request. The Plan says the items are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman interspinous device. 
 
You asked the Plan to pre-approve the Minuteman device. You say that this device is medically necessary, The 
Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Minuteman device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Minuteman device is experimental in spinal surgery. More research is 
needed. 
 
 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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman interspinous device.