Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 64719 rendered on June 2, 2023. 
 
You asked the Plan to pay for procedure code 64719. You say that this should be paid for. The Plan denied 
your request. The Plan says that procedure code 64719 is considered inclusive to CPT 64721. 
 
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 64719 
is a column II code to column I code 64721; however, 64719 was 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 code 64719. Our reviewer says that the 
documentation supports that procedure code 64719 should be paid. Our reviewer found that the procedure 
details cite the distal edge of the transverse carpal ligament and the underlying compressed and hypovascular 
median nerve exiting the carpal tunnel, which was released. Then a separate ulnar, palmar plan in the mid-
palmar incision, dissection was carried through the palmar fascia bringing into the loupe magnified view of the 
ulnar nerve and artery. The ulnar nerve was traced proximally back to Guyons canal with careful fascial 
dissection completely releasing the ulnar nerve. The wound was then irrigated and closed. Therefore, the 
documentation supports that procedure code was a separate and distinct procedure from procedure code 64721. 
 
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 code 64719 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 64719 rendered on June 2, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that this blood doctor is the only physician 
you will see. You say if your bloodwork is good, you do not need to this doctor for five years. You say you 
need the additional miles approved.  The Plan denied your request. The Plan says the benefit has been 
exhausted.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 miles per trip.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve the additional mileage.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 37616 billed for date of service October 31, 2022.  
 
You asked the Plan to pay for procedure code 37616. You say that the records provided support that the 
services billed were provided and medically necessary. The Plan denied your request. The Plan says that the 
billed number of units are not supported by the records as both provided and medically necessary.  
 
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 37616 is 1. The MAI value for this code is 3. You billed 3 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 37616. Our reviewer says that the services at 
issue in this case are supported by the medical records. Our reviewer found 4 arteries were ligated. The records 
support that these ligations were necessary and reasonable. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37616 have been met. Therefore, we decided that the Plan has to pay for 
procedure code 37616 billed for date of service October 31, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional Occupational Therapy additional visits. 
 
You asked the Plan to pre-approve the therapy services. You say that it is medically necessary for the enrollee's 
continued therapy services.  The Plan denied your request. The Plan says there is no clinical evidence to 
support the medical necessity of this examination or that the enrollee meets Medicare criteria for continued 
therapy services.  
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 the enrollee has had 10 sessions of occupational therapy and continues 
to require assistance with dressing, bathing, and toileting. The level of function has not changed with therapy. 
While the enrollee will likely continue to require assistance with daily activities, this does not require the 
services of a skilled occupational therapist. 
 
 
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 10 additional Occupational Therapy additional visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the requested PET scan is medically necessary. 
The Plan denied your request. The Plan says the requested PET scan does not meet the Medicare or health Plan 
coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is only noted to have memory 
problems. The records do not support a diagnosis of either AD or FTD, let alone both conditions. Therefore, 
the base requirement is not satisfied in this case. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  BRCA 1 and BRCA 2 Genetic Testing (70554). 
 
You asked the Plan to pre-approve  BRCA 1 and BRCA 2 Genetic Testing. You say that you have a family 
history of breast cancer. The Plan denied your request. The Plan says this test is not covered when used solely 
for screening purposes. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, BRCA 1 and BRCA 2 Genetic Testing, is being requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pre-approve  BRCA 1 and BRCA 2 Genetic Testing (70554).
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 will benefit from Acute Inpatient 
Rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan 
says the enrollee's condition does not meet the Medicare guidelines.  The Plan says that the services needed 
may be provided safely in a lower level of care.  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic mammography (77065) provided on May 1, 2023. 
 
You asked the Plan to pay for Mammogram testing. You say that medical documents submitted supports 
procedure code 77065 26 RT and is not a duplicate claim. The Plan denied your request. The Plan says this 
claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 1, 2023. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for Mammogram testing have not been met. Therefore, 
we decided that the Plan does not have to pay for diagnostic mammography (77065) provided on May 1, 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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet all the requirements for admission to an 
IRF.  
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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 evaluation and management services (procedure code 99223) 
rendered on April 6, 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 99223 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 high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 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 only 70 minutes were 
documented. Additionally, the decision making was only moderate 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 evaluation and management services (procedure code 99223) rendered on April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genicular nerve block rendered on April 18, 2023. 
 
You asked the Plan to pay for the block. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not billed with an appropriate diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered experimental/ investigational. Therefore, the request is deemed not medically 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 the block have not been met. Therefore, we decided that the Plan does not have 
to pay for a genicular nerve block rendered on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 13, 2023, 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 March 13, 2023, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery performed on April 5, 
2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you are unable to afford the 
cost share applied. 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 $370 
copayment for outpatient surgery.  
 
 
  You have been asked to pay a $370 copayment for outpatient surgery. This item/service falls within the 
outpatient surgery 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 an outpatient surgery 
performed on April 5, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that additional therapy is medically necessary 
for the enrollee. The Plan denied your request. The Plan says there is no clinical evidence to support the 
medical necessity of this examination or that the enrollee meets Medicare criteria for continued therapy 
services.  
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 continued therapy for pain by itself is not indicated and the enrollee 
can continue with a home exercise program. If the enrollee is not improving after 20 sessions of physical 
therapy, he should be reassessed by his physician. 
 
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 10 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99214 rendered on March 2, 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 that 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 99214 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 moderate level of medical decision 
making. When using time for code selection, 30-39 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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that as time is not documented in the 
medical record, CPT 99214 cannot be billed based on time. The documentation does note a detailed history and 
medical decision making of moderate complexity.  Therefore, CPT 99214 is supported based on 
documentation.  
 
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 99214 rendered on March 2, 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.