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

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service March 6, 
2023. 
 
You asked the Plan to pay for procedure code 64447. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 64447 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. 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 procedure code 
64447. Our reviewer says that 2 units of procedure code 64447 do not meet criteria for payment. Our physician 
reviewer found that two separate peripheral nerve blocks were performed and billed (vastus intermedius and 
genicular nerve). However, these are branches of the femoral nerve only and should be counted as only 1 unit 
of service for procedure code 64447. The records do not support that 2 units of the procedure denoted by code 
64447-59 were correctly coded. The allowed amount of units per day for this code is 1. 
 
We looked at this physician's review, the file, and Medicare rules. You did not provide all the required 
evidence showing that the excess units were correctly coded. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64447 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 64447 billed for date of service March 6, 2023.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for codes 99152 & 99153. We decided that the Plan does not have to pay 
for codes 36140, 36247, & 75625.  
 
You asked the Plan to pay for procedure codes 36140, 99152, 99153, 36247, & 75625 provided on December 
7, 2022.. You say that these services were medically necessary. The Plan says that the billed codes are not 
supported by the provide documentation. 
 
We decided that the Plan has to pay for codes 99152 & 99153.  
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
 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 codes 99152 & 99153. Our reviewer says 
that record contains documentation of a trained independent observer and the time spent at the patient's bedside 
while providing sedation. The criteria to report these codes has 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 codes 99152 & 99153 have been met. Therefore, we decided that the Plan has to 
pay for codes 99152 & 99153.  
 
We also decided that the Plan does not have to pay for codes 36140, 36247, & 75625. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
 
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 codes 36140, 36247, & 75625. Our reviewer 
says that these services are inclusive to another service billed and not separately payable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 36140, 36247, & 75625 have not been met. Therefore, we decided that 
the Plan does not have to pay for codes 36140, 36247, & 75625.  
 
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 waive the copayment for the ambulance transportation provided on 
January 28, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford 
the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for the ambulance transportation. This item/service falls within 
the ambulance 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 copayment for the 
ambulance transportation provided on January 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetics testing provided on January 5, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that pharmacogenetic testing is covered for the indications 
established in the applicable LCD.  
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 testing. Our reviewer says that the 
requested testing is not medically necessary. Our physician reviewer found that there is no documentation from 
the provider documenting the drugs being considered for use, and no documentation to how the results will 
impact treatment. The coverage criteria are not met for coverage of the requested PGx testing. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the pharmacogenetics testing provided on January 5, 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's admission to an LTACH is 
medically necessary. The Plan denied your request. The Plan says the enrollee is currently unstable for transfer 
to an LTACH. Coverage will continue for medically necessary acute and critical care at the current facility 
until the member's condition is stable for transfer to an alternate level of care (such as a skilled nursing 
facility), or until the clinical circumstances change such that LTACH may be reconsidered. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on March 
23, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $40 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 copayment 
for a specialist office visit provided on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assessment of and care planning for a patient with cognitive 
impairment provided on February 03, 2023. 
 
You asked the Plan to pay for assessment of and care planning for a patient with cognitive impairment. You 
say that the services should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for assessment of and care 
planning for a patient with cognitive impairment provided on February 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 13132 and 13121-59 billed for date of 
service July 5, 2022. 
 
You asked the Plan to pay for procedure codes 13132 and 13121-59. You say that these services were reported 
correctly and are supported in the medical records. The Plan denied your request. The Plan says these codes are 
not supported for the services provided. There are other codes which would report these services more 
accurately. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 13132 and 13121-59. Our reviewer says that 
the documentation does not support the services billed. Our reviewer found the procedure report documents, "closure was accomplished in layer, using 5.0 PDS in the dermis and 6.0 nylon continuous in the skin". In this 
case, there is a more appropriate code to report for service provided, which in this case is layered closure. 
Complex closures are not supported in the medical record and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 13132 and 13121-59 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 13132 and 13121-59 billed for date of service July 5, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 13, 2023. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in an 
assisted living facility. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve porcelain/ceramic dental crowns for teeth number 8 and 9  
(D2740 x 2). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that the requested dental items are not medically 
necessary.  
 
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. The Plan covers these dental 
items when medically necessary and reasonable. 
 
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 these dental items. Our reviewer says 
that the requested dental items are medically necessary. Our physician reviewer found that a review of the 
documentation indicates that teeth number 8 and 9 have vertical fractures as noted in the photographs. The 
enrollees symptoms of pain with biting pressure verifies cracked tooth syndrome. The standard of care is 
restoration with crowns to prevent fracture and to provide adequate function. The documentation provided 
meets the criteria for coverage of crown restorations.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of these dental items have been met. Therefore, we decided that the Plan has to 
pre-approve porcelain/ceramic dental crowns for teeth number 8 and 9 (D2740 x 2).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88342, 88341, 88368, 88369 and 88377 
billed for date of service January 25, 2023. 
 You asked the Plan to pay for procedure codes 88342, 88341, 88368, 88369 and 88377. You say that these 
services were necessary and were reported correctly. The Plan denied your request. The Plan says these 
services are not supported as separate charges. 
 
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 88342 is a column II code to column I code 88189, and codes 88368, 
88369 and 88377 are column II codes to column I codes 81270, 81339 and 81219; however, codes 88342, 
88341, 88368, 88369 and 88377 were each billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 88342, 88341, 88368, 88369 and 88377. 
Our reviewer says that the medical records do not support billing these codes with modifier 59. Our reviewer 
found these services were performed by the same physician during the same day and operative session as the 
column I codes. The medical records do not include sufficient documentation to validate the services at issue as 
separate/distinct services. Therefore, it is inappropriate to report these codes and use the 59 modifier. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 88342, 88341, 88368, 88369 and 88377 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 88342, 88341, 88368, 88369 and 
88377 billed for date of service January 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
cardiologist.  
 
You asked the Plan to pre-approve a continuation of care with an OON cardiologist. You say that you are an 
established patient of the OON provider. You say that switching providers would result in a loss of time and in 
more cost.  The Plan denied your request. The Plan says there are network providers who can supply the care 
needed.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of care with an OON 
cardiologist. Our reviewer says that the criteria for coverage of OON services have not been met. Our physician 
reviewer found there is nothing unique about your condition that would make it medically necessary to 
continue care with the OON provider. The Plan has shown that they have in-network specialists who have 
qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of 
your condition. Your medical management and/or follow-up care can be safely transitioned to an in-network 
specialist 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 a continuation of care with an OON cardiologist have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
cardiologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) 
unit. 
 You asked the Plan to pre-approve a TENS unit. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that TENS is only covered for certain indications. 
 
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 TENS unit. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician 
reviewer found you have lumbar radiculopathy. You have suffered from low back pain since 2018. Your pain is 
significantly worse in right buttocks after some type of ultrasound guided injection on December 23, 2022. The 
pain is sharp, achy, and dull but is slowly improving and is radiating to her posterior thigh. You received 
injections after failing to respond to three months of conservative therapy, such as nonsteroidal anti-
inflammatory drugs, physical therapy and a home exercise program. TENS units for low back pain are 
specifically excluded from coverage. Therefore, you do not meet criteria for the requested device.  
 
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 TENS unit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transcutaneous electrical nerve stimulation (TENS) unit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix wound care product. 
 
You asked the Plan to pre-approve Epifix. You say that the enrollee needs these grafts because the enrollee is 
in the process of healing. The Plan denied your request. The Plan says the records do not show improvement in 
any wounds with skin substitute therapy over many months' time. 
 
The Plan follows Medicare rules. Medicare rules state that cellular/tissue based products such as Epifix are 
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 Epifix. Our reviewer says that the 
enrollee does not meet criteria for the use of Epifix. Our physician reviewer found the records do not show 
improvement in any of the wounds with skin substitute therapy over many months' time. The enrollee does not 
meet the coverage indications for this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epifix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epifix wound care product.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 23, 2021. 
 
You asked the Plan to pay for the physician's services. You say that the first claim was billed timely. The Plan 
denied your request. The Plan says the claim was beyond 12 months of the date of service and denied for 
timely filing submission. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician's services was not filed until February 20, 2023. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on June 23, 2021.