Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for 20611 and 99214. We decided that the Plan does not have to pay for 
76881.  
 
You asked the Plan to pay for procedure codes 20611, 76881, and 99214 rendered on March 18, 2021.. You 
say that this should be paid for. The Plan says that the documents do not support this level of care. 
 
We decided that the Plan has to pay for 20611 and 99214.  
 
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 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 for CPT 20611 and 99214. Our reviewer says that the 
enrollee had bilateral artrocentesis with injection under ultrasound guidance. There is documented history, 
physical exam, and moderate level of decision making, given the interpretation of the ultrasound, and the need 
for injection. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
20611 and 99214.  
 
We also decided that the Plan does not have to pay for 76881. 
 
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 76881 is a column II code to column I code 20611. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for 76881. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs additional recovery 
time to allow a safe return home. The Plan denied your request. The Plan says the LTACH services requested 
do not meet the requirements for approval. 
 
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 appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23600 rendered on December 12, 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 Current Procedural Terminology (CPT) code 23600 54 (1 units) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 23600 is "Closed treatment of proximal humeral (surgical 
or anatomical neck) fracture; without manipulation." 
 
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 detailed documentation is not evident regarding the enrollee having been placed in the sling or any procedures performed on the right 
humerus fracture. Therefore, the documentation does not support that CPT 23600: closed treatment of proximal 
humeral (surgical or anatomical neck) fracture; without manipulation was rendered in this case. 
 
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 code 23600 rendered on December 12, 2022.
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 you are appealing the denial of the requested IRF 
admission. The Plan denied your request. The Plan says the enrollee does not meet 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 that the enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical 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: Partially Favorable

 
We decided that the Plan has to pay for 20611 and 99214. We decided that the Plan does not have to pay for 
76881.  
 
You asked the Plan to pay for procedure codes 20611, 76881, and 99214 rendered on March 18, 2021.. You 
say that this should be paid for. The Plan says that the documents do not support this level of care. 
 
We decided that the Plan has to pay for 20611 and 99214.  
 
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 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 for CPT 20611 and 99214. Our reviewer says that the 
enrollee had bilateral artrocentesis with injection under ultrasound guidance. There is documented history, 
physical exam, and moderate level of decision making, given the interpretation of the ultrasound, and the need 
for injection. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
20611 and 99214.  
 
We also decided that the Plan does not have to pay for 76881. 
 
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 76881 is a column II code to column I code 20611. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for 76881. 
 
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 pay for procedure code 36556 rendered on June 17, 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 CPT 36556 is included in CPT 93503 and cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
documentation does not support coverage of the central venous access CPT 36556 as central access is 
considered a component of the temporary cardiac pacemaker wire, a procedure that requires central venous 
access and was billed and covered as CPT 93503. CPT 36556 is not separately billable. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 36556 rendered on June 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration of the denied 
authorization based on medically necessity. The Plan denied your request. The Plan says the coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require daily skilled nursing and/or skilled therapy services. You are 
medically stable and can receive further rehabilitation services at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the knee x-ray provided on April 26, 2023. 
 
You asked the Plan to waive the copayment for the x-ray. You say that this should be fully covered with no 
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 $30 
copayment for in-network basic radiological services performed in a specialist's office.  
 
You have been asked to pay $27.70, which is less than the $30 copayment for an x-ray. This item/service falls 
within the outpatient diagnostic testing 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 knee x-ray provided on April 26, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided on March 30, 
2023, and March 31, 2023. 
 
You asked the Plan to pay for the medication. You say that these drugs should be covered. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided on March 30, 2023, and March 31, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 25, 2022. 
 You asked the Plan to pay for the office visit. You say that the services were not related to the enrollee's 
hospice diagnosis. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit provided on May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 11721-Q9 billed for date of service October 27, 2021. 
 
You asked the Plan to pay for code 11721-Q9. You say that code11721 was provided to address another one of 
the patients medical needs, regardless of the fact that both services are originated by diabetes, and therefore, 
you should have received the reimbursement for this professional procedure, rendered by our doctor. 
 The Plan denied your request. The Plan says code 11721-Q9 is not separately payable because it occurred 
during the global period of code 11421. 
 
The Plan must follow Medicare rules. Medicare rules say that if an unrelated procedure is performed during the 
postoperative period of a procedure that has a global period, providers must append modifier 79 to the 
unrelated procedure in order for the unrelated procedure to be separately paid. 
 
In this case, code 11421 was performed on October 18, 2021.  This code has a 10-day global period.  Nine days 
later (On October 27, 2021), you billed for code 11721-Q9. You claim that this service was unrelated to the 
first procedure, so it should be paid.  However, you did not bill this code with a modifier indicating that the service was unrelated to 11421.  Because no such modifier was billed, code 11721-Q9 is included in the global 
period of 11421, and no separate payment can be made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 11721-Q9 have not been met. Therefore, we decided that the Plan does not have to pay for 
code 11721-Q9 billed for date of service October 27, 2021.
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 April 5, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you cannot afford to pay for this service. 
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 April 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair and accessories. 
 
You asked the Plan to pre-approve a wheelchair and accessories. You say that the requested wheelchair and 
accessories are medically necessary. The Plan denied your request. The Plan says the enrollee resides in a SNF, 
and durable medical equipment is not covered by Medicare or the Plan when provided in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure. 
 
You asked the Plan to pre-approve the VivAer procedure. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says medical studies have not proven this service is helpful 
for the treatment of your health problem. 
 
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 VivAer procedure. Our reviewer 
says that the requested VivAer procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record indicates that the enrollee has nasal congestion and nasal turbinate 
hypertrophy. There is insufficient literature to support the safety and efficacy of the requested service for the 
enrollee's specific conditions. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Therefore, the reviewer found that this 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 the VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says this is considered experimental and therefore is not covered. 
 
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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this device is considered experimental as additional research is needed. Therefore, 
the reviewer found that the Vertiflex device 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bronchoscopy (31622), thoracoscopy with therapeutic 
wedge resection (32666, 32667), and thoracoscopy with pleurodesis (32650) to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the outpatient services. You say that this provider did your lung surgery 
three years ago. You say that you are only comfortable with this provider to do it again. You also say that this 
provider is familiar with your situation.  The Plan denied your request. The Plan says these services can be 
provided in-network.  
 
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 the outpatient services. Our reviewer 
says that the request for outpatient services to be provided out-of-network is not medically necessary. Our 
physician reviewer found there is insufficient documentation to support the need for the requested services to 
be performed by the requested out-of-network provider. The reviewer also found that there are credentialed, 
experienced physicians within the enrollees network who could be utilized for the enrollee's clinical condition. 
Therefore, the reviewer found that the request to receive these services out-of-network 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 the outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bronchoscopy (31622), thoracoscopy with therapeutic wedge resection (32666, 
32667), and thoracoscopy with pleurodesis (32650) to be provided by an out-of-network provider.