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

 
We decided that the Plan does not have to pre-approve repeat facet joint injection of the lower spine with 
sedation. 
 
You asked the Plan to pre-approve repeat facet joint injection of the lower spine with sedation. You say that 
this is medically necessary. The Plan denied your request. The Plan says this does not meet the LCD criteria for 
coverage. 
 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 repeat facet joint injection of the lower 
spine with sedation. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found the enrollee did not meet the required LCD criteria of  80% pain relief for each of the set of diagnostic 
blocks. Therefore, the request is deemed 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 repeat facet joint injection of the lower spine with sedation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve repeat facet joint injection of the lower spine 
with sedation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72020 for date of service July 21, 2023. 
 
You asked the Plan to pay for procedure code 72020. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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. 
 In this case, the CPT Code Manual definition of code 72020 is radiologic examination, spine, single view, 
specify level. 
 
We find that CPT code 72020 is not supported in the medical record. Specifically, the professional component 
of this code for the post-procedure imaging study is not separately payable and should not be reported. The 
technical component of the CPT code for the post-procedure imaging study may be reported. This means the 
code is not payable as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure code 72020 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 72020 for date of service July 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for you to 
receive the care needed. The Plan denied your request. The Plan says the services you need can be provided 
safely in another setting such as a skilled nursing facility, home with home health services or home with 
outpatient therapy.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF services would greatly improve your 
mobility and walking endurance. The Plan denied your request. The Plan says your last day of coverage was 
January 6, 2024, and you do not require further care at an SNF. 
 
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 an 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87486, 87498, 87541, 87581, and 87651 
billed for date of service September 7, 2023. 
 
You asked the Plan to pay for procedure codes 87486, 87498, 87541, 87581, and 87651. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says payment 
for codes 87486, 87498, 87541, 87581, and 87651 are bundled into payment for code 87801. 
 
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 codes 
87486, 87498, 87541, 87581, and 87651 are column II codes to column I code 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 87486, 87498, 
87541, 87581, and 87651 billed for date of service September 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracapsular cataract removal with insertion of 
intraocular lens prosthesis (66982-59-RT) provided March 3, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the 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. 
 
In this case, we have confirmed that code 66982 is a column II code to column I code 67113; however, 66982 
was billed with a modifier.  
 
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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The procedure report describes procedures performed on same 
anatomical area, and therefore would be inclusive to the more comprehensive procedure. In this case, separate 
billing 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the extracapsular cataract removal with insertion of intraocular lens prosthesis (66982-59-RT) 
provided March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 for date of service August 18, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that J69.0 has an Excludes1 note in relation to J18.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for procedure code 99233 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99233 for date of service August 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, and electronic 
connection for a power wheelchair. 
 
You asked the Plan to pre-approve expandable controller, harness, and electronic connection. You say that you 
are appealing this denial. The Plan denied your request. The Plan says the enrollee has no deficits in upper 
extremity sensation, range of motion, strength, coordination, or dexterity so can operate the wheelchair's power 
options. 
 
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 expandable controller, harness, and 
electronic connection. 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 use of the upper extremity 
and can operate and control the power options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller, harness, and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, and 
electronic connection for a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87799 and 87900 billed for date of service 
April 20, 2023. 
 
You asked the Plan to pay for the billed testing. You say that supporting documentation was provided. The 
Plan denied your request. The Plan says the billed codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that the pathogen testing used the 
nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or 
multiple kits were used in this case. As such, a single code with one unit of service should be used. Based on 
this information, we decided that Medicare rules for coverage of the testing panel have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87799 and 87900 billed for date 
of service April 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the necessity of LTACH services is 
paramount to ensure the best possible care and outcome for the enrollee. The Plan denied your request. The 
Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the medical records provided show that the enrollee is on supplemental oxygen 
and has non-complex wound care needs. The enrollee's needs do not meet the LTACH admission requirements. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology thyroid testing (81546) provided on June 28, 2023. 
 
You asked the Plan to pay for oncology thyroid testing. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot 
be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that diagnosis code E04.2 has an Excludes1 note in relation to code E01.0. This 
means that the two diagnosis codes cannot be reported together. Based on this information, we decided that the 
Medicare billing rules for oncology thyroid testing have not been met. Therefore, we decided that the Plan does 
not have to pay for oncology thyroid testing (81546) provided on June 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a bone and joint imaging service provided 
on September 01, 2023. 
 
You asked the Plan to waive the copayment for a bone and joint imaging service. You say that this service was 
a bone scan and should be fully covered. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $275 copayment for a bone and joint imaging service. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a bone and joint imaging service provided on September 01, 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 are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the enrollee has no daily skilled nurse or therapist needs. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testopel. 
 
You asked the Plan to pre-approve Testopel. You say that the enrollee has been using the requested drug every 
3 months for the past 4 years. The Plan denied your request. The Plan says medical studies have not proven the 
requested drug is safe and effective for the enrollee's condition.  
 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 Testopel. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has a normal testosterone level and elevated prostate specific antigen. The record provided is insufficient to 
establish that the coverage criteria are satisfied. The elements of the coverage criteria are not satisfied.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Testopel have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Testopel.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an initial and subsequent hospital care evaluation and 
management (99223, 99233) provided on December 10, 2022, to December 11, 2022. 
 
You asked the Plan to pay for hospital care evaluation and management. You say that you have submitted 
supporting documentation for reconsideration of the denied codes. The Plan denied your request. The Plan says 
code 99223 and 99233 remain 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. 
 
 
 
 
 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 hospital care evaluation and management. Our reviewer says 
that the services do not meet criteria for payment on this claim. Our reviewer found that for code 99223, the 
medical record includes an evaluation and management service provided on the date of admission. The 
documentation does not support a high level of medical decision making. Procedure report includes an 
appropriate history and examination, however, medical decision making includes review of laboratory 
procedures, endoscopy and further work up if continued drop or new onset of bleeding. Documentation does 
not support extensive number of diagnosis or management options; extensive data reviewed. There is a more 
appropriate code to report for documented service. For code 99233, the medical record does not include an 
evaluation and management report for December 11, 2022. Therefore, this procedure and date of service billed 
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 hospital care evaluation and management have not been met. Therefore, we 
decided that the Plan does not have to pay for an initial and subsequent hospital care evaluation and 
management (99223, 99233) provided on December 10, 2022, to December 11, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on February 26, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the records support a medically appropriate history and/or examination but do not support high level of 
decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on February 26, 2023.