Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional occupational therapy home health visits.  

You asked the Plan to pre-approve 2 additional occupational therapy home health visits. You say that the 
enrollee has not met goals and is debilitated due to chronic diagnosis. The Plan denied your request. The Plan 
says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 2 additional occupational therapy home 
health visits. Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found the clinical documentation shows that the enrollee requires assistance with dressing and 
colostomy management. However, clinically appropriate dressing and fine motor task goals have not been 
updated. Thus, the records do not show that 2 additional occupational skilled therapy visits would be required 
in the home setting to effectively provide treatment, care, and/or services in order to improve the enrollee's 
level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function 
and/or prevent deterioration. The Plan approved 2 out of the 4 requested visits and home health occupational 
therapy goals can be re-evaluated during that time frame.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 additional occupational therapy home health visits have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 2 additional occupational therapy home 
health visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure.  
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure received the 
Food and Drug Administration (FDA) clearance in 2016 and that clearance means the procedure in the eyes of 
the FDA is safe and efficacious. The Plan denied your request. The Plan says the requested Intracept procedure 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is no magnetic resonance imaging (MRI) showing only Modic changes 
without facet degenerative joint disease or foraminal stenosis. The cause of pain is not clear. 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for  the home health services provided from October 1, 2022, through 
October 19, 2022, billed with code GBPE1.  
 
You asked the Plan to pay for  the home health services as billed. You say that this period of care was 
approved, and the approved number of visits were provided.  The Plan denied your request. The Plan says that 
the approval was for HIPPS code GCPE, not GBPE. As such, the services were not approved and cannot be 
paid.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a valid denial rationale in this case. The HIPPS code 
that is billed on the claim is calculated by combining claim data with OASIS data. As such, the HIPPS code 
that is billed would be expected to differ from the HIPPS code requested for authorization based on the specific 
findings in the actual period of care and the services provided. The Plan has not provided a specific argument 
that the HIPPS code billed does not correctly represent the services rendered. As such, we find that this denial 
of payment is not substantiated. Therefore, we decided that the Plan has to pay for  the home health services 
provided from October 1, 2022, through October 19, 2022, billed with code GBPE1.   
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure.  
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that here is no magnetic resonance imaging (MRI) showing only Modic changes 
without facet degenerative joint disease or stenosis. The cause of pain is not clear. 
 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your 
request. The Plan says your benefit only allows 36 trips for this service. 
 
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.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 14, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you could 
not breathe after ant spray was sprayed in the house so an ambulance was called. You also say that when the 
ambulance arrived, you felt better and decided not to go to the hospital. The Plan denied your request. The Plan 
says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 14, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on May 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on April 5, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for wound care services. You say that it is medical necessity for these supplies. The 
Plan denied your request. The Plan says you must use network providers to get your medical care and services. 
If you go elsewhere without proper authorization you will have to pay in full. 
 
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 wound care services provided on April 5, 2023, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve revascularization with angioplasty and stent placement femoral 
popliteal tibial peroneal arteries (37226, 37230, 37225). 
 
You asked the Plan to pre-approve revascularization procedures. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or 
service, then that item or service will be covered when it is medically 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 revascularization procedures. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the documentation 
supports the medical necessity of the procedures in question. There is documentation that the enrollee has 
diabetes and an ulcer on the great toe that is worsening despite local treatment. The normal arterial study that 
was, in part, the basis for denial of angiography and possible intervention was from 2017. Although the 
vascular provider note is not included in the materials, an enrollee with diabetes and a worsening ulcer is at 
such high risk for limb loss that the risk of further delay is too high to demand assembly of all the records; 
there is enough documentation included demonstrating limb threat. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization procedures have been met. Therefore, we decided that the 
Plan has to pre-approve revascularization with angioplasty and stent placement femoral popliteal tibial peroneal 
arteries (37226, 37230, 37225).   
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 87481, 87653, and 87798 rendered on 
February 3, 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 these codes are not reimbursable separately. 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the laboratory report does not 
include any documentation to support the rationale of reporting an unusual non-overlapping service. Therefore, 
these codes and the modifier 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87481, 87653, and 87798 rendered on February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that you are in need of massage therapy due to 
mobility issues and to relieve muscle stiffness and pain. You say that you are on a medical financial assistance 
program and think massage therapy should be included. The Plan denied your request. The Plan says massage 
therapy is not covered per Medicare either for your specific condition or for any condition. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty at T12 (22513).  

You asked the Plan to pre-approve kyphoplasty at T12. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary 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 kyphoplasty at T12. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found detailed documentation is not 
evident regarding worsening pain. There is no indication of a progression of the body height loss, greater than 
25% vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is 
magnetic resonance imaging (MRI) corroboration of retropulsion and other plausible causes of back pain. 
Therefore, the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of v have not been met. Therefore, we decided that the Plan does not have to pre-
approve kyphoplasty at T12 (22513).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic services provided February 8, 2023. 
 
You asked the Plan to pay for the radiologic services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are 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 radiologic services. have not been met. Review of the file 
shows that the place of service 11 was billed; however, the documentation received does not support the 
services performed in an office or other outpatient setting, but rather in a mobile setting at a skilled nursing 
facility (SNF). There is a more appropriate place of service code (POS 15).  Therefore, we decided that the 
Plan does not have to pay for the radiologic services provided February 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 29580, 99348, and 99349 rendered from 
September 4, 2022, to September 18, 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 the records do not support the services billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 29580: 
 
Strapping; Unna boot 
 
CPT 99348: 
 
Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 
key components: An expanded problem focused interval history; An expanded problem focused examination; 
Medical decision making of low 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 presenting problem(s) are of low to moderate severity. 
Typically, 25 minutes are spent face-to-face with the patient and/or family 
 
CPT 99349: 
 
Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 
key components: A detailed interval history; A detailed examination; Medical decision making of moderate 
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 presenting problem(s) are moderate to high severity. Typically, 40 minutes are 
spent face-to-face with the patient and/or family 
 
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 in terms of CPT 29580, the 
procedure report does not describe Unna Boot strapping was performed on the dates of services billed. This 
code cannot be verified. 
 
In terms of CPT 99348 and CPT 99349, these procedures would not be reported in addition to the main service. 
The documentation does not support a separate service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 29580, 99348, and 99349 rendered from September 4, 2022, to September 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room visit, and 
injections provided from May 11, 2023, to May 15, 2023. 
 
You asked the Plan to waive the copayment for an in-network emergency room visit and injections. You say 
that you cannot afford these copayments, you thought you'd met the maximum out of pock amount. 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 $95 
copayment for emergency services, and a 20% coinsurance for Medicare Part B prescription drugs.  
 The allowed amount of this drug is $247.96, resulting in a coinsurance amount of $49.59 ($247.96 x 20%= 
$49.59). 
 
You have been asked to pay a $95 copayment for emergency services, and a $49.59 coinsurance for an in-
network emergency room visit and injections ($95 + $49.59= $144.59). This item/service falls within the 
emergency services and Medicare Part B prescription drugs 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 in-network emergency room visit, and injections provided from May 11, 2023, 
to May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you do not want to start all over with another 
provider. The Plan denied your request. The Plan says there are in-network providers in your health Plan that 
can provide the requested services. 
 
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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four units of G0277 rendered on March 22, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of Healthcare Common Procedure Coding System (HCPCS) code 
G0277 is "Hyperbaric oxygen (HBO) under pressure, full body chamber, per 30 minute interval."  
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 provider reported 4 units of 
service for hyperbaric services.  However, medical record documents time, "12:35 - 12:50; 13:30 - 14:45, and 
"Physician order: HBO at 2.5 ATA for 90 minutes of oxygen with 2 - five minute air breaks (30-05-30-05-
30)."  In this case, 4 units 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for four units of G0277 rendered on March 22, 2023.