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

 
We decided that the Plan does not have to pay for physician services (99223) provided on February 22, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the claim was billed with 
place of service 23. This place of service is not valid for codes billed. Based on this information, we decided 
that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the 
Plan does not have to pay for physician services (99223) provided on February 22, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 29, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the patient was not enrolled in hospice. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 12, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
and adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions, not to include cytology or biopsy procedures (D0431) provided on April 24, 2023. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the denial of payment for the 
services you received. The Plan denied your request. The Plan says these services are not covered under your 
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. Intraoral - complete series of 
radiographic images (D0210) and adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities 
including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) are not 
covered under the Plans dental benefits. 
 
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 pay for intraoral - 
complete series of radiographic images (D0210) and adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy 
procedures (D0431) provided on April 24, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for dry needling provided on March 2, 2023. 
 
You asked the Plan to pay for dry needling. You say that dry needling was medically necessary. The Plan 
denied your request. The Plan says that dry needling is excluded from coverage. The Plan says that the clinical 
value and effectiveness of thoracic and lumbar dry needling, in the setting of muscle spasms and tension 
causing back pain have not been demonstrated in the peer-reviewed literature. More research is needed to show 
safety and efficacy of the procedure. 
 
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 pay for dry needling. Our reviewer says that the 
requested dry needling is considered medically reasonable and necessary in this case. Our physician reviewer 
found that dry needling is used for trigger points and muscle spasm. It is 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 dry needling have been met. Therefore, we decided that the Plan has to pay for 
dry needling provided on March 2, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93976 and 93979 rendered on March 22, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the 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 93976: 
 
Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal 
organs; limited study 
 
CPT 93979: 
 
Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study 
 
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 abdominal ultrasound done on 
3/23/23 should have been coded with CPT 76700, which is abdominal ultrasound with doppler.  There is no 
indication for the additional doppler charges. 
 
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 93976 and 93979 rendered on March 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Feraheme. Our reviewer says that the 
documentation does not support that the requested drug is medical reasonable or necessary. Our physician 
reviewer found the enrollee has iron deficiency anemia. The lab work shows a hemaglobin level of 12.7. The 
documentation does not support that the enrollee meets 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 rendered on February 7, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the 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 96365: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour 
 CPT 96366: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(List separately in addition to code for primary procedure) 
 
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 procedure report describes 
Novolin R intravenous insulin treatment for an outpatient. In this case, there is a more appropriate code that 
should be reported for service provided. Of note, the infusion report does not include documentation of a start 
and end time, and therefore cannot be verified. 
 
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 96365 and 96366 rendered on February 7, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on February 26, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim processed appropriately as the criteria was met for CPT 99284. 
 
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 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 enrollee was treated 
with emergency room services (procedure code 99285) that were rendered on February 26, 2023. The enrollee 
was treated with Reglan and Benadryl which resolved their symptoms, and workup did not reveal an acute 
condition that required additional treatment or monitoring. The documentation from that date describes an 
appropriate history and physical for this encounter. However, the documentation from this encounter did not 
support a high level of medical decision-making as the enrollee only required symptom control and no other 
treatment.  
 
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 emergency room services (procedure code 99285) rendered on February 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the miscellaneous vision item provided on March 15, 2023.  
You asked the Plan to pay for the miscellaneous vision item. You say that you were told that your prescription 
eyeglasses would be covered in full. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not have this service listed as a covered benefit. 
 
We looked at the file and the Plan's rules. Specifically, the service is not a covered benefit. Based on this 
information, we decided that the Plan's rules for coverage of the miscellaneous vision item have not been met. 
Therefore, we decided that the Plan does not have to pay for the miscellaneous vision item provided on March 
15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for virtual services provided on January 27, 2023. 
 
You asked the Plan to pay for the virtual services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says no benefit coverage is available for virtual services performed by an 
out-of-network provider. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) are 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover that virtual care (also 
referred to as telehealth services, virtual check-ins or eVisits) out-of-network. Based on this information, we 
decided that Plans rules for coverage of the virtual services have not been met. Therefore, we decided that the 
Plan does not have to pay for virtual services provided on January 27, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on August 8, 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 claim was processed correctly, as the criteria was met for CPT 99284. 
 
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 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. 
 
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 emergency room services (procedure code 99285) rendered on August 8, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for the requested drug to be 
approved. 
 
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 Euflexxa. Our reviewer says that step 
therapy is required before the required drug can be approved. Our physician reviewer found the enrollee has 
not tried and failed the required drugs, Monovisc, Orthovisc, Synvisc or Synvisc One. The documentation 
provided does not indicate that the Plan's required drugs would likely be less effective or 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11042 provided on March 29, 2023. 
 
You asked the Plan to pay for procedure code 11042. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a valid primary diagnosis. 
 
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 11042 is not supported in the medical record. Specifically, diagnosis codes E11.621 
(Type 2 diabetes mellitus with foot ulcer) and E08.621 (Diabetes mellitus due to underlying condition with foot 
ulcer) have an exclude note and cannot be billed together. Based on this information, we decided that Medicare 
rules for coverage of procedure code 11042 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 11042 provided on March 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile radiology services provided on March 10, 2023, billed with codes 74240, 74230, 92611, 72040, 70100, and 70310.

You asked the Plan to pay for the mobile radiology services as billed. You say that these services were medically necessary and should be paid. The Plan denied your request. The Plan says this claim was billed with an inappropriate POS code.

The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, they are often provided to serve an entity for which another Place of Service (POS) code exists. If the mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity. However, if the mobile unit is not serving an entity which could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15.

We looked at the file and Medicare rules. This claim was billed with POS code 11, for office setting. However, the documentation shows that this service was provided in the mobile setting. There is no evidence that this service was provided at a doctor's office. Based on this information, we decided that Medicare rules for coverage of the mobile radiology services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the mobile radiology services provided on March 10, 2023, billed with codes 74240, 74230, 92611, 72040, 70100, and 70310.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for closed treatment of tibial fracture, proximal (plateau); 
without manipulation rendered on December 2, 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 Current Procedural Terminology (CPT) code 27530-54, RT (1 Unit) remains 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 27530 is "Closed treatment of tibial fracture, proximal 
(plateau); without manipulation." 
 
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 enrollee was being treated for 
a closed fracture of the shaft of the right distal fibula, likely with a deltoid ligament injury. The enrollee 
presented to the emergency department for an injury of the leg after a fall. The exam reveals tenderness over 
the patella. There is bilateral ankle swelling. The x-rays revealed the ankle injury findings. The treatment notes 
state a splint was applied to immobilize the right ankle using Ortho glass and stirrup. Therefore, the records do 
not support that CPT 27530 was rendered or supported in this case. 
 
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 closed treatment of tibial fracture, proximal (plateau); without manipulation rendered on 
December 2, 2022.