Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 29, 
2022, through May 3, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient care was medically 
necessary. The Plan denied your request. The Plan says the enrollee could have been managed in the outpatient 
setting.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee is a 73-year-old female who presented to the emergency department with 
itchiness and dizziness, and an incidental finding of a clotted dialysis catheter was noted. A catheter exchange 
procedure was not initially performed as expected due to the enrollee being on Plavix, but she was given 
Activase with plan for possible surgery on admission if not successful and after stopping Plavix. Activase was 
not successful after two doses, and the enrollee underwent catheter exchange surgery two days later which was 
successful. However, at the time of admission, the enrollee was stable and did not require urgent dialysis and 
could have completed the surgery as outpatient. Therefore, it was not expected that the enrollee would have 
required hospital care that would have likely crossed 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from April 29, 2022, through May 3, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on 
May 3, 2023. 
 
You asked the Plan to pay for the bitewings - four radiographic images. You say that you had cleaning and 
annual x-rays were done on May 3, 2023 and they were denied. You also say that the x-ray done on March 23, 
2023 was for a crown that came off and the doctor wanted to make sure there was no decay before re-attaching. 
The Plan denied your request. The Plan says your benefit for the bitewings - four radiographic images has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service March 23, 2023. Therefore, we 
decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on May 
3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 17, 
2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 17, 2023, to January 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cryosurgical ablation. 
 
You asked the Plan to pre-approve cryosurgical ablation. You say that the enrollee prefers to undergo 
cryoablation as opposed to surgery. The Plan denied your request. The Plan says the evidence is insufficient to 
determine the effects of the technology on health outcomes. 
 
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 cryosurgical ablation. Our reviewer 
says that the requested cryosurgical ablation is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has been described in the records as technically a surgical candidate 
and has been explained that surgery is "the gold standard" for the diagnosis. The enrollee does not wish to go 
forward with surgery. Rather the enrollee has requested percutaneous cryoablation therapy. The reviewer found 
this type of therapy is usually reserved for those that are poor surgical risks or have other contraindications to 
the accepted therapy for malignancy. The reviewer also found that the request in this case seems to be at the 
enrollee's insistence rather than the recommendation of her physician. Therefore, the reviewer found that the 
requested cryosurgical ablation 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 cryosurgical ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cryosurgical ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services/other/percutaneous access and closure 
of femoral artery provided on November 4, 2022. 
 
You asked the Plan to pay for practitioner services/other/percutaneous access and closure of femoral artery . 
You say that the services were medically necessary. The Plan denied your request. The Plan says we have 
insufficient documentation to corroborate the services so we cannot confirm Medicare coverage has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of practitioner 
services/other/percutaneous access and closure of femoral artery have been met. Therefore, we decided that the 
Plan does not have to pay for practitioner services/other/percutaneous access and closure of femoral artery 
provided on November 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service November 6, 
2022, to December 2, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service November 6, 2022, to December 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 18, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on February 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 provided 
on March 30, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, 96521, and J1817. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered as 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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is refilling and maintenance of portable pump. The definition of code J1817 is insulin for administration through DME (i.e., insulin pump) 
per 50 units. 
 
We find that CPT codes 96365, 96366, 96521, and J1817 are not supported in the medical record. Specifically, 
the records show that outpatient intravenous insulin treatment (OIVIT) was performed and there is a more 
appropriate set of codes for these services. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 96365, 96366, 96521, and J1817 provided on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for shockwave therapy provided on April 3, 2023. 
 
You asked the Plan to reimburse you for shockwave therapy. You say that these treatments could prevent 
surgery and also save you and the Plan money. The Plan denied your request. The Plan says this service is not 
covered by the Plan or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
 We looked at the file and Medicare rules. The file shows that this provider does not participate in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for shockwave therapy provided 
on April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 26, 
2023, to April 22, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service March 26, 2023, to April 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 11, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider 
such as an urgent or an emergent situation that has been documented.  
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on November 11, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiologic examination, gastrointestinal tract, upper (code 74240) 
provided on January 7, 2023. 
 
You asked the Plan to pay for radiologic examination, gastrointestinal tract, upper. You say that this service is 
unique and not a duplicate. The Plan denied your request. The Plan says that this claim is a duplicate of a claim 
that has already been considered for payment. 
 
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. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the Plan has not provided a remittance 
that shows another claim has been considered for payment. Based on this information, we decided that 
Medicare rules for coverage of radiologic examination, gastrointestinal tract, upper have been met. Therefore, 
we decided that the Plan has to pay for radiologic examination, gastrointestinal tract, upper (code 74240) 
provided on January 7, 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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99213. We decided that the Plan does not have to pay 
for procedure code 20611.  
 
You asked the Plan to pay for procedure codes 20611 and 99213 billed for date of service August 1, 2022.. You 
say that you have billed the services at issue correctly. The Plan says that the provided records do not support 
procedure code 20611. Payment for code 99213 is bundled into code 20611. 
 
We decided that the Plan has to pay for procedure code 99213.  
 
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 99213 
is a column II code to column I code 20611; however, 99213 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 99213. Our reviewer says that procedure 
code 99213 meets criteria for payment. Our physician reviewer found that additional medical decision making 
was performed that was not related to the injection, such as addressing the knee instability with a brace. The 
use of modifier 25 is supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99213 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99213.  
 
We also decided that the Plan does not have to pay for procedure code 20611. 
 
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 (eg, shoulder, hip, knee, 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 procedure code 20611. Our reviewer says that procedure 
code 20611 does not meet criteria for payment. Our physician reviewer found that the record does not state that 
permanent ultrasound recording was performed and stored in the record. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 20611 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 20611. 
 
  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99233) provided on January 18, 2023 to 
January 19, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 99233 is evaluation and management of a patient, 
requiring a medically appropriate history and/or examination, and medical decision making of high complexity. 
 
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 physician services. Our reviewer says that the records do 
not support the code billed. Our reviewer found the records do not show a comprehensive history or medical decision making of high 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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99233) provided on January 18, 2023 to January 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology (cutaneous melanoma), mRNA, gene 
expression profiling testing (81529). 
 
You asked the Plan to pre-approve oncology (cutaneous melanoma), mRNA, gene expression profiling testing. 
You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that molecular diagnostic tests are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve oncology (cutaneous melanoma), 
mRNA, gene expression profiling testing. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the records did not clearly show that there was a concern for adequacy of 
microstaging on the most recent pathology report. There was not a calculated greater than 5% presumed risk 
for spreading to justify this testing as it had a low mitotic rate and clear margins. Therefore, the LCD criteria 
for this testing is not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oncology (cutaneous melanoma), mRNA, gene expression profiling testing have 
not been met. Therefore, we decided that the Plan does not have to pre-approve oncology (cutaneous 
melanoma), mRNA, gene expression profiling testing (81529).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from intensive rehab to 
address their deficits and help bring the enrollee as close to functioning baseline as possible. The Plan denied 
your request. The Plan says an IRF admission is not medically necessary.  
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.