Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker you purchased on December 22, 2022. 
 
You asked the Plan to pay for the walker. You say that you were traveling to visit your daughter and your 
walker was damaged by the airline on the way.  You said that you needed to purchase a new walker since you 
use it 100% of the time. The Plan denied your request. The Plan says you purchased this walker from an 
ineligible provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider from 
whom you purchased the walker is not enrolled in the Medicare program. Therefore, we decided that the Plan 
does not have to pay for the walker you purchased on December 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires close medical 
monitoring with daily physician management for their complex medical needs. The Plan denied your request. 
The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to a 
LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found with the enrollee's clinical progress note from October 19 that they are afebrile 
without leukocytosis, on an oral diet and room air. The enrollee does not meet criteria for LTACH, and their 
medical needs are being met in the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance, when performed (64454). 
 
You asked the Plan to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance. You say that this is medically necessary. The Plan denied your request. The Plan 
says this 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 injection(s), anesthetic agent(s) and/or 
steroid; genicular nerve branches, including imaging guidance. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered experimental therapy. It is the subject of ongoing clinical trials.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-
approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, 
when performed (64454).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this care to regain 
prior level of functioning. The Plan denied your request. The Plan says medical records do not support the need 
for an LTACH admission and, the enrollee's needs can be managed at the current facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's care can be safely provided at the current facility until they are more 
stable and appropriate for transfer to another 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20600 billed for date of service December 6, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the claim. The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
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. The file shows that the services at issue were reimbursed by the Plan 
on January 21, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed services were provided twice on the same date.  Based on this information, we decided that the Medicare rules for the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 20600 billed for date of service 
December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospitalist visits (99223 and 99233) provided on July 1, 2023 
and July 2, 2023. 
 
You asked the Plan to pay for 99223 and 99233. You say that these codes were used correctly. The Plan denied 
your request. The Plan says the records do not support the level of decision-making or time components for 
these codes. 
 
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 99223 is initial hospital 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 are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. The CPT Code Manual definition of code 99233 is subsequent hospital care, per day, for the evaluation 
and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; 
A detailed examination; 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 patient is unstable or has 
developed a significant complication or a significant new problem. Typically, 35 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 99223 and 99233. Our reviewer says that these codes do not 
meet criteria for payment. Our reviewer found for code 99223, the documentation supports a comprehensive 
examination, but not a comprehensive history or medical decision-making of high complexity. For code 99233, 
the documentation supports a detailed examination, but not a detailed 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 99223 and 99233 have not been met. Therefore, we decided that the Plan does 
not have to pay for hospitalist visits (99223 and 99233) provided on July 1, 2023 and July 2, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on May 5, 2023, to May 7, 2023, billed 
with codes 99291 and 36556. 
 
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 that documentation does not support the billed 
codes. 
 
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 
codes 99291 and 36556 is critical care, evaluation and management of the critically ill or critically injured 
patient; first 30-74 minutes, and insertion of non-tunneled centrally inserted central venous catheter; age 5 
years or older. 
 
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 practitioner services provided. Our reviewer says that 
documentation does support the billed codes. Our reviewer found that the documentation supports the provision 
of critical care and the time spent providing the care. In addition, the procedure note documents the placement 
of a non-tunneled, central venous catheter. The catheter is not noted to be tunneled, the procedure note does not 
document tunneling. As such, the billing of CPT 36556 is supported. 
 
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 practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on May 5, 2023, to May 7, 2023, billed with codes 99291 and 
36556.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you have several doctor appointments 
coming up that you need rides for and you will soon be out of trips. You also say that you have started 
canceling appointments because you would not have a way to get to the more important appointments.  The Plan denied your request. The Plan says your request for additional rides beyond the 30 one-way rides 
exceeds the benefit limit. The Plan also says once those rides are exhausted, there are no additional rides 
available to other healthcare related locations. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 20 
additional routine transportation trips for your appointments. Based on this information, we decided that you 
have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that 
the Plan does not have to pre-approve 20 additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 27, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that the claim is for the fire service and not any 
type of ambulance service. The Plan denied your request. The Plan says without transport there is no payable 
charge. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 27, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 27, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 5, 2023, to April 11, 
2023, billed with codes A4221 and A4222. 
 
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 these services are not covered. 
 
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 codes A4221 and A4222 are not supported. Specifically, the billed codes have an MUE of 0 
and are statutorily excluded. 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 April 5, 2023, to April 11, 2023, billed with codes A4221 and A4222.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an indirect crown (D2710).  
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
indirect crown (D2710).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96413, 93675, 96367, 96417, 96415 and 
96416 billed for date of service February 27, 2023.  
 
You asked the Plan to pay for procedure codes 96413, 93675, 96367, 96417, 96415 and 96416. You say that 
these services were necessary and are supported as billed. The Plan denied your request. The Plan says these 
codes are not supported in the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our 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 codes 96413, 93675, 96367, 96417, 96415 and 
96416. Our reviewer says that these codes are not supported in the records provided. Our reviewer found there 
is no documentation to support the start and stop time of chemo and infusion, as well as the push of the drug, and what was being given. 
 
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 codes 96413, 93675, 96367, 96417, 96415 and 96416 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 96413, 93675, 96367, 
96417, 96415 and 96416 billed for date of service February 27, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an ultralightweight wheelchair and accessories (K0005 E0950 
E0951 E0961 E2211 E2212 E2607 E2619 E2620 K0038 K0040 K0108). 
 
You asked the Plan to pre-approve a wheelchair. You say that the enrollee has been in a K0005 for the past 13 
years. An ultralightweight wheelchair and accessories are medically necessary and justified. The Plan denied 
your request. The Plan says that the requested ultralightweight wheelchair with accessories is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 wheelchair. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of traumatic brain injury with spasticity and is unable to functionally 
ambulate and requires a manual wheelchair for mobility. The enrollee cannot propel a manual wheelchair and 
requires caregiver assistance to do so. While the enrollee is unable to propel a manual wheelchair, the enrollee 
still requires an ultralight manual wheelchair given the ability to adjust its axle for stability, which is required 
per the mobility evaluation for the safety of the enrollee. The enrollee currently has an ultralight manual 
wheelchair that is over 5 years of age and in need of replacement. Therefore, the ultralight manual wheelchair 
is medically 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 wheelchair have been met. Therefore, we decided that the Plan has to pre-approve an ultralightweight wheelchair and accessories (K0005 E0950 E0951 E0961 E2211 E2212 E2607 
E2619 E2620 K0038 K0040 K0108).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services described by codes 74240, 74230, 
72040, 70100, and 70310 performed on February 21, 2023. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services should be paid as 
billed because each code represents a distinctly different procedure that was medically necessary. The Plan 
denied your request. The Plan says the radiology services are denied because they were billed with an 
inappropriate POS. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology services performed in the mobile 
setting are not eligible for reimbursement if they are listed in the Exclusions from Coverage as Portable X-Ray 
Services section of the Medicare Benefit Policy Manual. Medicare rules also state that claims must be billed 
with the appropriate POS.  
 
We looked at the file and Medicare rules. Documentation provided shows codes 74240 and 72430 were 
performed in a mobile unit setting with the use of fluoroscopy. Therefore, they are not covered and are 
excluded under the portable x-ray provision. Codes 72040, 70100, and 70310 were billed with POS 11, 
indicating an office setting. However, documentation shows the radiology services were performed in a mobile 
setting. There is no evidence the services were provided in an office setting. Based on this information, we 
decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiology services described by codes 74240, 74230, 72040, 70100, 
and 70310 performed on February 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service June 29, 
2023. 
 
You asked the Plan to pay for the billed services. You say that more payment is expected. The Plan denied your 
request. The Plan says the code is not substantiated by the 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 code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
 
 We find that CPT code 99285 is not supported in the medical record. The records show that the enrollee 
presented to the emergency room with groin swelling. The enrollee was not in pain. Testing was provided and a 
diagnosis of balanitis was determined. The enrollee was prescribed ointment. The records do not show that a 
high level of medical decision making of was provided. 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 99285 billed for date of service June 29, 2023.