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

 
We decided that the Plan has to pay for the services described by procedure code(s) 64450. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 12001.  
 
You asked the Plan to pay for procedure codes 64450 and 12001 provided on May 18, 2023. You say that you 
would like the Plan to reconsider their denial of payment. The Plan says that the services are not covered. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 64450.  
 
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 64450 is Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch.  
 
We find that CPT code 64450 is supported in the medical record. Specifically, the records show that a digital 
block was performed. Additionally, diagnosis codes S61227A and S68625A can be billed together in this case 
as the records show they were unrelated. The diagnosis codes represent two different fingers on the left hand. 
Based on this information, we decided that Medicare rules for coverage of 64450 have been met. 
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
12001. 
 
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 12001 is Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or 
extremities (including hands and feet); 2.5 cm or less. 
 
We find that CPT code 12001 is not supported in the medical record. Specifically, the records do not show that 
there was any kind of repair made. Based on this information, we decided that Medicare rules for coverage of 
12001 have not been met. Therefore, we decided that the Plan does not have to pay for the services described 
by procedure code(s) 12001. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on December 10, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99285. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
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 99285. Our reviewer says that the medical 
records do not support the billing of code 99285. Our reviewer found the enrollee was seen in the emergency 
department for flank pain related to renal colic. At issue is the accuracy of billing code 99285. The medical 
records do not support comprehensive history or exam, nor is the 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 procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on December 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that percutaneous vertebral 
augmentation is medically necessary. The Plan denied your request. The Plan says percutaneous vertebral 
augmentation does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is covered when 
the criteria listed in the Medicare rules section of this decision 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 percutaneous vertebral augmentation. 
Our reviewer says that the requested percutaneous vertebral augmentation is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that there is no documentation of trial of 
bracing. More conservative measures are needed for fracture 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 percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (80307, G0483) billed for date of 
service April 19, 2023. 
 
You asked the Plan to pay for drug testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not 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 drug testing have been met. 
Specifically, the results of the testing services at issue have not been provided for review. The services at issue 
cannot be verified. Therefore, we decided that the Plan does not have to pay for drug testing services (80307, 
G0483) billed for date of service April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96360, 96361 and A4649 billed for date of 
service July 26, 2023. 
 
You asked the Plan to pay for procedure codes 96360, 96361 and A4649. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says codes 96360 and 96361 have been 
billed with an invalid Place of Service code. Code A4649 is a bundled/excluded code. 
 
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 96360 and 96361 have a Professional/Technical Component flag of 5. This 
means that payment cannot be made for these services when they are provided to hospital inpatients or patients 
in a hospital outpatient department. The services at issue were billed with Place of Service (POS) code 23, 
indicating services provided at the emergency room of a hospital. Codes 96360 and 96361 are not payable 
when provided in the indicated setting. 
 
We find that procedure code A4649 has a Status Indicator of P on the Physician Fee Schedule. This means that 
procedure code A4649 is a bundled/excluded code. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 96360, 96361 and 
A4649 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96360, 
96361 and A4649 billed for date of service July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 10061 billed for date of service May 1, 2023. 
 
You asked the Plan to pay for the billed service. You say that medical records were submitted. 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 10061 is incision and drainage of abscess (e.g., 
carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); 
complicated or multiple. 
 
 
 
 We find that CPT code 10061 is not supported in the medical record. Specifically, the records do not show that 
complicated or multiple incision and drainage services were provided. There is a more applicable code 
available that describes the services provided. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
10061 billed for date of service May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral medial branch block (MBB). 
 
You asked the Plan to pre-approve bilateral medial branch block. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says it is 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 bilateral medial branch block. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the results on the imaging report indicate that there is non-facet pathology 
that may be causing the enrollee's pain. Medicare policy criteria requires documentation that there is no non-
facet pathology per clinical assessment or radiology study that could explain the source of the patients pain. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral medial branch block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bilateral medial branch block (MBB).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that the treatment sought was medically necessary. 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. The file shows that a combined cardio and pharmacogenetic test panel was provided. We looked at the file and 
Medicare rules. This claim was billed with the laboratory POS code. The records do not support that the sample 
was taken in a laboratory setting. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on November 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G2023) provided on March 2, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that under skilled nursing facility (SNF) Prospective 
Payment System (PPS) all Medicare covered Part A services that are considered within the scope or capability 
of SNFs are considered paid in the PPS rate. In some cases this means that the SNF must obtain some services 
that it does not provide directly. Neither the SNF nor another provider or practitioner may bill the program for 
the services under Part B. 
 
We looked at the file and Medicare rules. Payment for the billed services is included in the SNF PPS rate. The 
services are not separately payable. 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 
(G2023) provided on March 2, 2023.
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 cannot walk and spending a lot of time in bed 
requiring 24/7 care. The Plan denied your request. The Plan says your records do not show that you require 
daily skilled services that can be provided only on an inpatient basis in a SNF. The Plan says the skilled 
services you require, on a less intensive basis, can safely be received at a different setting, home with home 
health, in residential care, or home with close follow-up with your physician. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric seat-lift mechanism (E0627). 
 
You asked the Plan to pre-approve an electric seat-lift mechanism. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 an electric seat-lift mechanism. Our 
reviewer says that an electric seat-lift mechanism is not medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require a power seat lift chair. The enrollee has low-back pain with mobility and performing transfers, but there is no indication that the enrollee cannot independently 
perform transfers. There is no indication of severe hip or knee osteoarthritis or a neuromuscular condition that 
significantly impairs the enrollee's ability to perform transfers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electric seat-lift mechanism have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electric seat-lift mechanism (E0627).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. The Plan denied your request. The Plan says 
epidural steroid injections are 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 epidural steroid injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the previous transforaminal epidural steroid injections did not provide at 
least 50% of sustained improvement in pain relief and/or improvement in function for at least 3 months. 
Therefore, the enrollee does not meet the LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Via Disc NP. 
 
You asked the Plan to pre-approve Via Disc NP. You say that the requested Via Disc NP is medically 
necessary. The Plan denied your request. The Plan says the requested Via Disc NP is 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 Via Disc NP. Our reviewer says that the 
requested Via Disc NP is not considered medically reasonable and necessary. Our physician reviewer found the 
Via Disc NP device is experimental. More research is 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 Via Disc NP have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Via Disc NP.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography and the duplex scan provided on 
August 14, 2023. 
 
You asked the Plan to pay for the echocardiography and the duplex scan. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the echocardiography 
and the duplex scan provided on August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99236 billed for date of service June 6, 2023. 
 
You asked the Plan to pay for the billed service. You say that the code accurately reflects the treatment 
provided. The Plan denied your request. The Plan says the billed code was 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 99236 is hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and high level of medical decision making. 
 
 
 
 We find that CPT code 99236 is not supported in the medical record. The medical records provided do not 
show that the enrollee was discharged on the date of service at issue. Based on this information, we decided 
that Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99236 billed for date of service June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 7, 2023, billed 
with procedure code 93042. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the place of service is inappropriate for the 
procedure. 
 
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 93042 is rhythm ECG, 1-3 leads: interpretation and 
report only. 
 
We find that CPT code 93042 is not supported in the medical record. Specifically, the billed code has not been 
billed with modifier 25. Based on this information, we decided that Medicare rules for coverage of the 
practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on February 7, 2023, billed with procedure code 93042.