Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an intraoral comprehensive services of radiographic images (D0210) 
and a panoramic radiographic image (D0330) provided on May 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that your benefit for the requested item or service has already been 
exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for an intraoral comprehensive services of 
radiographic images (D0210) and a panoramic radiographic image (D0330) provided on May 2, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99232) provided on April 27, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99232 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 99232 is not supported by the records provided. Our reviewer found that the medical records submitted do not support 
moderate level of medical decision making or total time required of the billed code. 
 
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 the services (99232) provided on April 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's condition or in widespread use for this patient's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request is unproven and 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that genicular artery embolization is considered to be experimental/ investigational at this 
time. Therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular artery embolization.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service May 16, 
2023. 
 
You asked the Plan to pay for procedure code 0245U. You say that the co-diagnostic testing provides risk 
stratification. The Plan denied your request. The Plan says payment for code 0245U is bundled into payment 
for code 0018U. 
 
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 0245U is a column II code to column I code 0018U. The records 
show that the tests at issue are a combination testing. The medical records provided do not show that the 
service, billed with the -59 modifier, was a distinct procedural service. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
0245U billed for date of service May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure codes 99232 
and 99233) rendered from January 10, 2023, to January 16, 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 services are not supported without the required 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 the denied codes is: 
 
CPT 99232: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision 
making. When using total time on the date of the encounter for code selection, 35 minutes must be met or 
exceeded 
 
CPT 99233: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records during these dates 
supported an appropriate history and examination, however, they did not support a moderate or high level of 
decision making and did not support a duration of each encounter to justify the use of these codes using the 
time requirement. Therefore, the CPT codes, 99232 and 99233 are not appropriate for these encounters. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure codes 99232 and 99233) rendered from 
January 10, 2023, to January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an external ambulatory insulin infusion pump with supplies. 
 
You asked the Plan to pre-approve insulin infusion pump. You say that an insulin pump will help the enrollee. 
The Plan denied your request. The Plan says that the enrollee does not meet criteria for this pump. 
 
The Plan follows Medicare rules Medicare rules state that insulin pumps may be covered if certain 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 insulin infusion pump. Our reviewer 
says that the enrollee meets criteria for this pump. Our physician reviewer found as the C-peptide is 
undetectable at less than 0.01 and the enrollee has a history of Type I diabetes, there is little doubt that the 
enrollee has insulinopenia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insulin infusion pump have been met. Therefore, we decided that the Plan has to 
pre-approve an external ambulatory insulin infusion pump with supplies.  
 
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 procedure code 99223-AI billed for date of service April 5, 
2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the service was already billed and paid. 
 
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 find that CPT code 99223-AI is not supported. The claim information shows that code 99223-AI was billed 
during the same inpatient period by the same provider. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 99223-AI billed for date of service April 5, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the enrollee has been experiencing 
high-risk symptoms. The Plan denied your request. The Plan says the record does not show that this is 
medically necessary without attempting less-invasive testing and evaluation first. 
 
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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a negative radionuclide stress test earlier in 2023. The records 
provided do not support the rationale for this invasive imaging study. Guidelines do not support a need for 
cardiac catheterization in this setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
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 services are medically necessary for the enrollee 
to receive the care needed in order to return back home and prevent further complications. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable. There are no acute rehab nursing needs identified or 
documented. The documents received do not support necessity for admission to an IRF. The complexity of the 
enrollees medical, rehab, and nursing needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. The enrollees rehab needs can be safely provided in an 
alternate and low intensity setting such as in a skilled nursing facility.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not specify any plan of care or provider order for any specific home health service thus the 
records do not show that skilled nursing or skilled therapy services are required to effectively provide 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81000) provided on March 24, 2023. 
 You asked the Plan to pay for laboratory services. You say that this testing was necessary. The Plan denied 
your request. The Plan says this claim is missing the CLIA number and cannot be processed without it. 
 
The Plan must follow Medicare rules. Medicare rules say that any independent laboratory performing tests 
covered by CLIA must submit the CLIA number on the claim. Laboratory claims submitted without the 
required CLIA number are returned as unprocessable. If the CLIA number is submitted on the claim, but is 
inconsistent with the CLIA format, the A/B MAC (B) returns the claim as unprocessable. 
 
We looked at the file and Medicare rules. This claim was submitted without a CLIA number. Based on this 
information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, 
we decided that the Plan does not have to pay for laboratory services (81000) provided on March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 28, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring Active Compression Garment 
System (codes K1024 and K1033). 
 
You asked the Plan to pre-approve a Koya Dayspring Active Compression Garment System. You say that the 
Plan's denial reasons are inaccurate as the prescribed treatment is medically necessary and the information 
provided substantiates the level of service. The Plan denied your request. The Plan says there is insufficient 
evidence in the medical literature to demonstrate that the Koya Dayspring Active Compression Garment 
System is an effective treatment modality for the treatment of lymphedema, as compared to other treatment 
modalities. The Plan also says there is insufficient evidence in the medical literature to support that the 
requested Dayspring device is as effective as a pneumatic sequential compression device. 
 
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 Koya Dayspring Active Compression 
Garment System. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found this specific device does not currently have 
sufficiently supportive evidence to show long-term benefit or benefit over standard compression devices. 
 
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 Koya Dayspring Active Compression Garment System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Koya Dayspring Active Compression 
Garment System (codes K1024 and K1033).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Shenopalatine ganglion block. 
 
You asked the Plan to pre-approve a Shenopalatine ganglion block. 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. 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 Shenopalatine ganglion block. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Sphenopalatine ganglion blocks are considered 
experimental/investigational for the treatment of migraines. Therefore, the request is deemed not medically 
reasonable and necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Shenopalatine ganglion block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Shenopalatine ganglion block.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0480, 80307, and 83789 billed for date of 
service May 8, 2023. 
 
You asked the Plan to pay for the billed services. You say that testing is necessary to monitor possible opioid 
abuse. The Plan denied your request. The Plan says the billed codes are 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. 
 The CPT Code Manual definition of code 80307 is presumptive drug testing. We find that CPT code 80307is 
not supported in the medical record. The records do not show that presumptive testing was provided on this 
date of service. 
 
The CPT Code Manual definition of code G0480 is definitive drug testing of 1-7 drug classes. We find that 
CPT code G0480 is not supported in the medical records. There is insufficient medical records to show that the 
drug testing was ordered based on suspicious behaviors, self-escalation of dose, doctor-shopping, 
indications/symptoms of illegal drug use, evidence of diversion, or other clinician documented change in affect 
or behavioral pattern. 
 
Medicare rules say that providers performing validity testing on urine specimens utilized for drug testing 
should not separately bill the validity testing. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes G0480, 80307, and 83789 billed for date of service May 8, 2023.