Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99053 and 99220 rendered on June 6, 2022. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 99053: 
 
Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service 
 
CPT 99220: 
 
Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of 
high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
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 CPT 99220 is not supported in 
the records. Although there was a detailed history and physical documented, there was not sufficient evidence 
of medical decision making of high complexity in the notes. 
 
Additionally, CPT 99053 has a status indicator of B. This means that this code is not appropriate to report or be 
paid separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99053 and 99220 rendered on June 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox at a rate of 500 units per 91 days. 
 
You asked the Plan to pre-approve 500 units of Botox per 91 days. You say that the requested treatment is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested treatment is off-
label and not medically accepted. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 500 units of Botox per 91 days. Our 
reviewer says that the prescribed quantity of the requested drug is not medically reasonable and necessary in 
this case. Our physician reviewer found that Botox at a dose of 500 units/91 days is not FDA-approved. This 
use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-
approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 500 units of Botox per 91 days have not been met. Therefore, we decided that 
the Plan does not have to pre-approve treatment with Botox at a rate of 500 units per 91 days.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services on December 22, 2022. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service 
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 item or service was exhausted on date of service March 29, 2022. 
Therefore, we decided that the Plan does not have to pre-approve the dental services on December 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that Prolia is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says step-therapy rules for coverage of Prolia have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a history of osteoporotic fracture or a trial of zoledronic acid before they will approve the 
requested drug, Prolia. Records do not indicate that the enrollee has a history of osteoporotic fracture or that the 
enrollee has tried and failed the required drug. Based on the medical records provided and the Medicare-
approved major drug compendia, there is no indication that the Plan's required drug would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee arthroscopy (29881). 
 
You asked the Plan to pre-approve the knee arthroscopy. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has 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 the knee arthroscopy. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no clear indication of a failure of physical therapy or any injection therapy 
for the left knee. Additionally, there is clear evidence of osteoarthritis of the left knee. More conservative 
measures are needed. 
 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 knee arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a knee arthroscopy (29881).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service provided on June 28, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that you disagree with the processing of the 
claim and are asking for a review. The Plan denied your request. The Plan says when transferring a patient 
from one facility to another that transport is included in the facility charge. The claim denied because services 
should be included in the hospital's contract rate. There is no coverage for transport from hospital to hospital. 
 The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital it 
may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care 
while the beneficiary maintains inpatient status with the original provider. 
 
We looked at the file and Medicare rules. The records provided demonstrate that the enrollee was receiving 
inpatient hospital care at the time of the transport. This means that the transportation service furnished to the 
enrollee while they were admitted as inpatient would be covered as an inpatient hospital and not paid for 
separately under Part B. Based on this information, we decided that Medicare rules for coverage of the 
ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
service provided on June 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on November 22, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require or waive prior authorization rules for obtaining POS services. The Plan contract says that outpatient 
rehabilitation services require prior authorization. 
 
We looked at the file and Medicare rules. The physical therapy services at issue were not authorized. Based on 
this information, we decided that Medicare rules for coverage of physical therapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided on November 
22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp cap-indirect (excluding final restoration) (D3120) 
provided on January 3, 2023.  
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under your 
supplemental dental policy. 
 
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 service provided is not among 
those covered under this benefit.   
 
Therefore, we decided that the Plan does not have to pay for the pulp cap-indirect (excluding final restoration) 
(D3120) provided on January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99309) provided on November 22, 
2022. 
 
You asked the Plan to pay for the nursing facility care. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 99309 is not supported in the medical record. Specifically, the claim was billed with a 
Skilled Nursing Facility place of service, however records show the enrollee was in custodial care and not 
receiving skilled services. Based on this information, we decided that Medicare rules for coverage of the 
nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay for nursing 
facility care (99309) provided on November 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
November 17, 2022. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that this service was medically 
necessary. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are 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 codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
November 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Vertiflex device is experimental. More research is needed to demonstrate its 
safety and efficacy. 
 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 procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the criteria for approval have 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 as of the last covered day, the enrollee had no skilled nursing or rehab services 
on a daily basis. The enrollee was not expected to make measurable gains within a reasonable and predictable 
period of time or require skilled therapy to prevent deterioration with mobility or self-care tasks. The enrollee 
did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the 
enrollee did not require any skilled services on an inpatient basis, at a skilled level of care as of 04/24/2023. 
The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding 
tube. The enrollee's function was at or near his new baseline level of function and he could be discharged to a 
lower level of care for further services. As of 04/24/2023 only custodial services were needed. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service December 
23, 2022. 
 
You asked the Plan to pay for procedure code 77062. You say that the services were medically necessary. 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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service December 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection(s), platelet rich plasma, any tissue, including 
image guidance, harvesting and preparation when performed (0232T) provided November 29, 2022. 
 You asked the Plan to pay for platelet rich plasma injections. You say that you have attached the medical 
records to prove medical necessity. The Plan denied your request. The Plan says this service is not covered by 
Medicare. The records do not show evidence that these injections were used for the treatment of chronic non-
healing wounds. 
 
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 pay for platelet rich plasma injections. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee with a history of rheumatoid arthritis who 
received platelet rich plasma injections to the bilateral midfoot. The review indicates that the Platelet rich 
plasma injections and/or applications are considered not medically reasonable and necessary for any use 
outside of the National Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic Non-
Healing Wounds. The records do not show evidence that these injections were used for the treatment of chronic 
non-healing wounds. The review has determined that the requested item is not medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of platelet rich plasma injections have not been met. Therefore, we decided that 
the Plan does not have to pay for the injection(s), platelet rich plasma, any tissue, including image guidance, 
harvesting and preparation when performed (0232T) provided November 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the criteria for approval have 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 the documentation does not support that you require skilled nursing services with 
the specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively provide 
care only in a SNF. You do not have any complex wound care needs, IV antibiotics, enteral feedings, or other 
skilled nursing needs during these dates that require a SNF admission. Your functional level does not require 
the skills of a professional therapist only in a skilled nursing facility.  You do not require these services on a 
daily basis. As a practical matter, your needs do not require the necessary services on an inpatient basis in a 
SNF. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on October 21, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that the submitted medical records  show the 
services were medically necessary. The Plan denied your request. The Plan says the documentation does not 
support medical necessity as the member was able to sit in a wheelchair and there is no documentation that 
some means of transportation other than an ambulance could not be used without endangering the individual's 
health. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service. Our reviewer says 
that the ambulance transport was not medically necessary.  Our physician reviewer found vital signs were notable for diastolic hypotension, tachycardia, and tachypnea. 
Inspection of the right leg demonstrated minor swelling, with normal sensation and bilateral pedal pulses. The 
enrollee was informed that the emergency medical service could only provide transport to a local hospital. The 
enrollee initially refused transport, but then agreed. The enrollee did not appear to be in any pain or discomfort 
and remained in stable condition. The enrollee's diagnoses included pain in right lower leg, and localized 
swelling, mass and lump, right lower limb. The documentation supported that the ambulance transport was 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 ambulance service have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport provided on 
October 21, 2022.