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

 
We decided that the Plan does not have to pay for procedure codes 93042 and 99285 rendered on December 15, 
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 93042: 
 
Rhythm electrocardiogram (EKG), 1-3 leads; interpretation and report only 
 
CPT 99285: 
 
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 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 documentation supports a 
comprehensive exam, but not a comprehensive history or medical decision making of high complexity. The 
records do not support the presenting problems were of high severity, posing an immediate threat to life and 
function. The records show an EKG being done, but not why CPT 93042 would be a separate and distinct 
procedure from CPT 99285. 
 
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 93042 and 99285 rendered on December 15, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on March 1, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is a non-Medicare approved/certified 
freestanding emergency facility.  
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on March 1, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator for 9 months. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the enrollee has chronic 
obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA) with associated chronic respiratory 
failure and has been treated with Trilogy ventilator, therefore, it is less than optimal care to withdraw a therapy 
that the enrollee is compliant with and working. Hence, best practice is to continue with the trilogy ventilator. 
 
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 ventilator for 9 months have been met. Therefore, we decided that the Plan 
has to pre-approve a ventilator for 9 months (E0466).  
 
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 reimburse you for a radiologic examination of the foot provided on 
February 21, 2023. 
 
You asked the Plan to reimburse you for the radiologic examination of the foot. You say that you will have the 
proof of payment sent to go with reimbursement. The Plan denied your request. The Plan says you did not 
submit proof of payment with your reimbursement form.  
 
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 the radiologic examination of the foot have been met. Proof of payment was not submitted to the Plan with your reimbursement form. Therefore, we 
decided that the Plan does not have to reimburse you for a radiologic examination of the foot provided on 
February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798 
billed for date of service January 13, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, and 87798. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87150, 87481, 
87641, 87653, and 87798 is bundled into payment for other 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, we have confirmed that code 87150 
is a column II code to column I code 87500. We have confirmed that codes 87481, 87641, 87653, and 87798 
are a column II codes to column I codes 87150 and 87801. This claim has not been billed with an appropriate 
modifier to bypass the edit. 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 codes 87150, 87481, 87641, 87653, and 
87798 billed for date of service January 13, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Vabysmo. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of diabetes mellitus with diabetic retinopathy with macular edema. The 
documentation does not support that the enrollee has tried and failed bevacizumab (Avastin). The 
documentation does not support that bevacizumab (Avastin) would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for intravenous infusion services billed with code 96366 for date of service 
January 16, 2023. 
 
You asked the Plan to pay for the intravenous infusion services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that code not appropriate for the service billed. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan has denied this service due to code not 
appropriate for the service billed. The documentation does not include an explanation on why the code is not 
appropriate for the service billed. No other denial rationale was provided. The Plan did not substantiate their 
denial. Therefore, we decided that the Plan has to pay for intravenous infusion services billed with code 96366 
for date of service January 16, 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 application of a modality to 1 or more areas; hot or cold 
packs (97010), not a code used (S8263), application of a modality to 1 or more areas; infrared (97026) 
provided from November 30, 2022, through January 4, 2023. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the 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. 
 
Code S8263 is not a recognized Current Procedural Terminology (CPT) code with a description, and per peer 
to peer with provider's office, is meant for internal office use only related to delivery of the oral prosthesis. Per 
Centers for Medicare & Medicaid Services (CMS) guidelines NCD 270.6, there is sufficient evidence to 
conclude the use of infrared therapy devices and any related accessories is not reasonable and necessary under 
section 1862(a)(1)(A) of the Social Security Act (the Act). Furthermore, procedure code 97010 has a status 
indicator of B on the Physician Fee Schedule indicating that it is 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 application of a modality to 1 or more areas; hot or cold packs 
(97010), not a code used (S8263), application of a modality to 1 or more areas; infrared (97026) provided from 
November 30, 2022, through January 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pairing of corn or callus (11055, 11056) provided on 
April 18, 2023. 
 
You asked the Plan to pay for the pairing of corn or callus. You say that the enrollee was seen for the 
assessment and evaluation of lower extremities, including skin, feet and toenails. You say that the enrollee also had six or more toenails debrided and two lesions cut which were separate services for different reasons. You 
also say that these services should be paid. The Plan denied your request. The Plan says the documentation 
does not support evidence of severe peripheral involvement for which these services would be covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not a covered Medicare benefit 
unless you have diabetic foot disease or some other condition that makes professional care of your feet 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Part C Plan was correct in denying the request to pay for the pairing of corn or callus. Our 
reviewer says that the requested pairing of corn or callus is not medically necessary. Our physician reviewer 
found the provided documentation does not indicate a diagnosis of diabetes, peripheral vascular disease, or 
neurologic condition. The reviewer found that the enrollee was seen for routine foot care on the date of services 
in this case where paring of these lesions was performed. The medical records indicate normal lower extremity 
peripheral pulses and normal neurologic sensation. There was no documentation of advanced trophic changes 
of the skin, claudication, edema, or temperature changes. Therefore, the reviewer found that the paring of 
hyperkeratotic lesions (corns or calluses, coded as 11055 and 11056) is not medically necessary. Therefore, we 
decided that the Plan does not have to pay for the pairing of corn or callus (11055, 11056) provided on April 
18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trigger point injections (20552) provided on March 27, 2023. 
 
You asked the Plan to pay for trigger point injections. 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 list the ICD-10-CM codes that support medical necessity. 
The diagnosis reported on the claim at issue is not listed as a code that supports medical necessity. Based on 
this information, we decided that Medicare rules for coverage of trigger point injections have not been met. 
Therefore, we decided that the Plan does not have to pay for trigger point injections (20552) provided on 
March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
when two power seating functions/actuators/motors are provided, one unit of E2311 is allowed. The Plan 
denied your request. The Plan says although there are three requested power options (tilt, recline and elevating 
leg rests), there is not a medical need to control these power options through the joystick. 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has decreased strength in their 
right upper extremity but 4 out of 5 strength in their left upper extremity with normal range of motion. Our 
reviewer also found that the enrollee has adequate upper body strength to manage standard power drives. 
 
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 electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72131 billed for date of service December 
21, 2022.  
 
You asked the Plan to pay for procedure code 72131. You say that the claim should be paid. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 72131 is one (1). The MAI value for this code is 3. You billed two (2) 
units of this code, exceeding the MUE. You did not provide all the required evidence showing that the excess 
units were actually provided, were correctly coded, and were medically necessary. Based on this information, 
we decided that Medicare rules for coverage of procedure code 72131 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 72131 billed for date of service December 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you would like to see another provider because he s the 
only provider that specializes in movement disorder. The Plan denied your request. The Plan says this is 
available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker provided on March 03, 2023. 
 
You asked the Plan to pay for a walker. You say that the supplies should be covered. 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 a walker provided on 
March 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 24, 2023, to February 28, 
2023. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 an office visit provided 
on January 24, 2023, to February 28, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy and an office visit provided on December 14, 
2022. 
 
You asked the Plan to pay for psychotherapy and an office visit. You say that this service is supported in the 
records. 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 psychotherapy and an 
office visit provided on December 14, 2022.