Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for the billed service. You say that no modifier is required. The Plan denied your 
request. The Plan says the service is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99283 was billed with patient status code 21, defined as a discharge or transfer to 
court/law enforcement. Based on this information, we decided that Medicare rules for coverage of the billed 
service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99283 
billed for date of service August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 25, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, sedation, and face bone graft provided on 
March 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that your dentist sent you for emergency dental care. 
You say that you were not aware that this provider did not accept Medicare payment. You also say that you 
cannot afford to pay for this as you are on a fixed income. The Plan denied your request. The Plan says the 
provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services 
performed by a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Additionally, there were no records provided to support that the services in this case were urgent or emergent in nature. Therefore, we decided that the Plan does not have to 
pay for the office visit, sedation, and face bone graft provided on March 7, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require IRF care in order to return home safely. 
The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found your condition is in fact complex and fragile, and there is every reason to expect that you will participate 
in and benefit from IRF level services to include at minimum physical therapy, occupational therapy, physician 
oversight of cardio/renal function and polypharmacy, and case manager coordination of any additional services 
that might be needed to make a sustainable return, as well as avoid preventable readmissions to the acute 
hospital. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued inpatient psychiatric treatment from 
October 28, 2023, forward. 
 
You asked the Plan to pre-approve continued inpatient psychiatric treatment. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says this admission is not medically 
necessary beginning October 28, 2023. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric 
treatment. Our reviewer says that the requested for continued inpatient psychiatric treatment is not medically 
necessary. Our physician reviewer found the provided documentation indicates that it was not expected this 
enrollee would improve in a reasonable period of time beyond the dates in question as they did not show any 
dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not 
showing any acute threats of safety. Therefore, the reviewer found that the request for continued inpatient 
psychiatric treatment is not medically reasonable or 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 continued inpatient psychiatric treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continued inpatient psychiatric treatment from October 28, 
2023, forward.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that a home ventilator is not medically necessary. 
 
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. Our reviewer says 
that a home ventilator is medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has obesity hypoventilation syndrome (OHS) and has been on average volume-assured pressure 
support (AVAPS) via trilogy home ventilator since 2021. To withdrawal this therapy would not be best 
practice. The enrollee should continue on home ventilator as previously prescribed, and step-down therapy 
would be inappropriate. 
 
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 have been met. Therefore, we decided that the Plan has to 
pre-approve a home ventilator (E0466).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health treatment. 
 
You asked the Plan to pre-approve continued inpatient mental health treatment. 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 must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient mental health 
treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based 
upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of October 31, 2023, forward and could have been treated 
in a lesser restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, delusions and was not showing any behaviors or aggression. He was being cooperative and 
compliant while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient mental health treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient mental health treatment.
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 requested IRF services are medically necessary. 
You would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
the enrollee does not meet Medicare guidelines for services in 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7120) provided on June 22, 2023. 
 
You asked the Plan to pay for D7120. You say that you believe the Plan should pay for this. The Plan denied 
your request. The Plan says this service has been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a surgical 
extraction (D7120) provided on June 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 20611 billed for date of service June 15, 2023. 
 
You asked the Plan to pay for code 20611. You say that medical records were provided to support payment. 
The Plan denied your request. The Plan says code 20611 is not supported by the medical record. The records 
indicate that an injection was performed at the first metatarsophalangeal (MTP) joint, which is not considered a 
major joint. Code 20610 should have been billed instead. 
 
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 20611 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (e.g., shoulder, hip, knee or subacromial bursa with ultrasound guidance, with permanent 
recording and reporting). 
 
 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 code 20611. Our reviewer says that code 20611 is not 
supported by the medical record. Our reviewer found the injection was performed in the foot, not in shoulder, 
hip, knee or subacromial bursa with ultrasound guidance, with permanent recording and reporting, which 
would support the billing of 20611. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 20611 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 20611 billed for date of service June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 5, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on June 30, 2023, billed with 
codes 87150, 87798 and 87484. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on June 30, 2023, billed with codes 87150, 87798 and 87484.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218) billed for 
dates of service March 16, 2023, to April 6, 2023. 
 
You asked the Plan to pay for the fluid circulating cold pad with pump (E0218). You say that this item was 
medically necessary. The Plan denied your request. The Plan says this item is not covered. The Plan must 
follow Medicare rules. Medicare rules say that fluid circulating cold pads with pump (E0218) are non-covered.  
Therefore, we decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218) 
billed for dates of service March 16, 2023, to April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services coded as G3002 performed on 
June 30, 2023. 
 
You asked the Plan to pay for G3002. You say that G3002 should be paid as billed because it is supported in 
the medical record. The Plan denied your request. The Plan says G3002 is denied because it is not supported in 
the documentation. 
 
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 G3002 is chronic pain management and treatment, 
monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating 
scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan 
that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health 
literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care 
coordination between relevant practitioners furnishing care, e.g. physical therapy and occupational therapy, 
complementary and integrative approaches, and community-based care, as appropriate. required initial face-to-
face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes 
personally provided by physician or other qualified health care professional, per calendar month. (When using 
G3002, 30 minutes must be met or exceeded.) 
 
We find that CPT code G3002 is not supported in the medical record. The record does not include 
documentation of the enrollee-specific items from the code definition of G3002 that were performed, such as 
administration of a validated pain rating scale or tool, the enrollee's specific objective pain rating, their goals, 
clinical needs, or desired outcomes. Based on this information, we decided that Medicare rules for coverage of 
G3002 have not been met. Therefore, we decided that the Plan does not have to pay for the pain management 
services coded as G3002 performed on June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 31, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that the medical records were provided. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a combined cardio and pharmacogenomics panel test was provided. We looked at the file 
and Medicare rules. This NGS panel was not billed with a single code as required. The records do not show 
that the enrollees treating physician ordered the test for a specific medical problem. Medicare does not cover 
this testing for screening purposes. Based on this information, we decided that Medicare rules for coverage of 
the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on January 31, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 
81241, 81291, 81306, 81328, 81335, and 81479.
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 needs an LTACH admission. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care and is currently 
unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary. The enrollee's needs do 
not meet the requirements for an LTACH admission. It is expected the enrollee's remaining and acute care 
needs can be met in his current setting with subsequent transfer to a lower level of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that your provider is recommending this 
procedure and you cannot afford to pay for it out of pocket. The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
core buildup (D2950).