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

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case.  
Our physician reviewer found that in this case, there is no documented concordant radiological image-based 
diagnostic testing supporting cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication 
due to disc herniation, osteophyte or osteophyte complexes, or severe degenerative disc disease, producing 
foraminal or central spinal stenosis. The review has determined that the requested epidural steroid injection 
does not meet the Medicare 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services provided by a Certified Registered Nurse 
Anesthetist (CRNA) on November 3, 2021.  
 
You asked the Plan to pay for the CRNA services. You say that this is a payable service.  The Plan denied your 
request. The Plan says that this provider type cannot be paid for this service. 
 
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. The Plan's rationale is not valid. It is indicated that this provider type cannot be 
paid for anesthesia services. Medicare does allow CRNAs to be paid for anesthesia. As such, the denial of 
payment is not substantiated. Therefore, we decided that the Plan has to pay for the anesthesia services 
provided by a Certified Registered Nurse Anesthetist (CRNA) on November 3, 2021.   
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the spring-powered lancet device provided on November 17, 2022, 
billed with code A4258.  
 
You asked the Plan to pay for the spring-powered lancet device. You say that the records support payment for 
these services.  The Plan denied your request. The Plan says that the use of modifier -KX is not valid, and the 
number of units of A4258 exceed limitations. 
 
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. The Plan offered two denial rationales neither of which is supported. It is 
indicated that modifier -KX cannot be used because the enrollee is not insulin-treated. The records clearly 
indicate that the enrollee uses insulin. It is also noted that the code A4258 has exceeded the number of units 
allowed. No evidence was provided to show this code was previously covered, nor that the one unit billed 
exceeds any limitations. We find that the denial of payment is not substantiated. Therefore, we decided that the 
Plan has to pay for the spring-powered lancet device provided on November 17, 2022, billed with code A4258.   
 
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: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to waive $10 of the cost share applied for an injection, x-ray, elbow orthosis, 
and OT services. We decided that the Plan does not have to waive $177.49 of the cost share for an injection, 
x-ray, elbow orthosis, and OT services.  
 
We decided that the Plan has to waive $10 of the cost share applied for an injection, x-ray, elbow 
orthosis, and OT services.  
 
The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). The Plan failed to forward information to support their charges of 
$187.49. Therefore, we decided that the Plan has to waive the cost share for an injection, x-ray, elbow orthosis, 
and OT services.  
 
We also decided that the Plan does not have to waive $177.49 of the cost share for an injection, x-ray, 
elbow orthosis, and OT services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). According to the Plan contracted amount for each service, you owe 
a total cost share of $177.49. 
 
Date of Service Service Rendered Amount Allowed Amount per 
Contract 
Cost Share 
October 19, 2022 OT Evaluation 
(97166) 
$98.67 $25 copayment $25 
October 28, 2022 Elbow Orthosis 
(L3762) 
$55 20% coinsurance $11 
October 28, 2022 OT services 
(97535) 
$32.08 $25 copayment $25 
November 04, 2022 OT services 
(97110) 
$28.82 $25 copayment $25 
November 10, 2022 OT services 
(97110) 
$28.82 $25 copayment $25 
November 17, 2022 OT services 
(97140) 
$26.50 $25 copayment $25 
December 6, 2022 Radex Elbow 
Complete x-ray 
(73080) 
$31.52 $15 copayment $15 
December 6, 2022 OT services 
(99213) 
$74.03 $25 copayment $25 
December 6, 2022 Injection (J1030) $7.45 20% coinsurance $1.49 
Total     $177.49  
Therefore, we decided that the Plan does not have to waive $177.49 of the cost share for an injection, x-ray, 
elbow orthosis, and OT services. 
 
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 code 99152 billed for October 5, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99152 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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of the amount of face-to-face time the anesthesia was given. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99152 billed for October 5, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on September 20, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the tested were performed as ordered by the 
referring physician. The Plan denied your request. The Plan says that this claim is not covered. 
 
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. In this case medical records are needed to review the medical necessity of this 
testing. Only the lab report was provided. There is no evidence that the Plan attempted to obtain the medical 
records. Without this information we are unable to verify that the claim was denied correctly. Therefore, we 
decided that the Plan has to pay for the laboratory services provided on September 20, 2022.  
 
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 the critical care services provided on September 13, 2022.  
 
You asked the Plan to pay for the critical care services. You say that this should be paid. The Plan denied your 
request. The Plan says this service was provided within the 90-day postoperative period of code 32540 and is 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that postoperative follow-up visits are included in the 
global payment for a surgical service. In order to report a service that is unrelated to follow-up for the surgery, 
modifier -24 must be used.  
 We looked at the file and Medicare rules. This service was provided within the global period of a major 
surgical procedure. No modifier was reported to allow separate payment. Based on this information, we 
decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided 
that the Plan does not have to pay for the critical care services provided on September 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
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. Our reviewer says that the 
documentation does not support that the requested ventilator is medically reasonable or necessary. Our physician reviewer found the enrollee has diagnosis of chronic obstructive pulmonary disease. The provided 
records in this case do not fully support a diagnosis of chronic hypercapnic respiratory failure consequent to 
chronic obstructive pulmonary disease for which a mechanical ventilator would be indicated. Provided records 
do not clarify that the home ventilator is not being requested for use in a mode that could be provided by a 
BiPAP device with average volume assured pressure support (AVAPS) and a back-up rate. Provided records do 
not document trial and failure of a BiPAP device with AVAPS and a back-up rate. Therefore, the enrollee does 
not meet criteria for the requested device. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the unlisted endocrine surgery procedure (60699) provided on June 27, 
2022. 
 
You asked the Plan to pay for the outpatient surgery. You say that the medical records support the billed codes. 
The Plan denied your request. The Plan says that the service was not authorized. 
 
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 the outpatient surgery. Our reviewer says 
that the outpatient surgery is considered medically reasonable and necessary in this case.   Our physician 
reviewer found the provided documentation indicates the enrollee had a history of thyrotoxicosis from a thyroid 
nodule. The documentation indicates that the enrollee was admitted for radiofrequency ablation under 
ultrasound guidance. The reviewer found that the billing of 60699 is supported in the records. Therefore, the 
reviewer found that the outpatient surgery 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 the outpatient surgery have been met. Therefore, we decided that the Plan has to 
pay for the unlisted endocrine surgery procedure (60699) provided on June 27, 2022.  
 
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 the services (77427) provided on November 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly 
 
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 services have been met. The non-
contract provider did not submit medical records for the date of service in question. The records submitted only 
consisted of a weekly management note dated November 17, 2022. Therefore, we decided that the Plan does 
not have to pay for the services (77427) provided on November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99239) provided on March 3, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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 99239 is "Hospital discharge day management; more than 
30 minutes". 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that 
more than 30 minutes of hospital discharge management services were provided on the date in question. 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 (99239) provided on March 3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the Part B injectable provided on August 31, 2022. 
 
You asked the Plan to pay for the Part B injectable. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the service was not medically necessary. 
 
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. It appears that the Plans contracted delegate was provided the records for the 
services and has failed to forward them to support the decision to deny based on no medical necessity. The Plan 
based their denial partially on Medicare criteria and without the medical records we cannot verify if the 
enrollee met criteria or not. Therefore, we decided that the Plan has to pay for the Part B injectable provided on 
August 31, 2022.  
 
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 code 99292 billed for date of service July 23, 2022. 
 
You asked the Plan to pay for code 99292. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed this code inappropriately. 
 
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 99292 is critical care, each additional 30 minutes, and is 
used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care. 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, the medical records 
explicitly state that 34 minutes were spent on critical care on the date of service in question.  It is not 
appropriate to bill code 99292 unless the total time of critical care exceeds 74 minutes, which it does not in this case. Based on this information, we decided that Medicare rules for coverage of code 99292 have not been met. 
Therefore, we decided that the Plan does not have to pay for code 99292 billed for date of service July 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99212) rendered on June 30, 
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 provider did not bill as required by Medicare coding regulations. 
 
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 99212 is not supported in the medical record. Specifically, this code represents the initial evaluation for a surgery (CPT 10030) and was billed on the same day as the surgery. As the surgery has 
a global period of 0 days, the evaluation cannot be reported separately on the same day. 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 an office visit (procedure code 99212) rendered on June 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services (95928, 
95925, 95860) provided on September 20, 2022. 
 
You asked the Plan to pay for the IONM services. You say that the services should be covered. The Plan 
denied your request. The Plan says the IONM services were 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 pay for the IONM services. Our reviewer says that the requested IONM services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found there is a lack of high-quality clinical evidence that the provision of IONM services 
during shoulder surgery. The reviewer found that there is a need for further study of monitoring services in 
such procedures. Therefore, the reviewer found that the IONM services were not medically reasonable or 
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 the IONM services have not been met. Therefore, we decided that the Plan does 
not have to pay for the intraoperative neuromonitoring (IONM) services (95928, 95925, 95860) provided on 
September 20, 2022.