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

 
We decided that the Plan does not have to pay for procedure code 99213-25 rendered on January 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 this code cannot be separately reimbursed. 
 
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 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 
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 CPT code 36482 codes for the 
Venaseal procedure and associated evaluation and management work performed on the day of the 
procedure. This code has already been billed and covered. There is no documentation suggesting that 
additional, unrelated evaluation and management services were provided on that day to justify billing or 
coverage of 99213-25. 
 
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 code 99213-25 rendered on January 26, 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 the LTACH services. You say that LTACH services are medically 
necessary. You would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says the enrollee does not meet Medicare guidelines for care in an 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 that there is no documentation provided indicating medical necessity for admission to 
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the destruction by neurolytic agent, paravertebral facet 
joint nerves (64635, 64636) 
 
You asked the Plan to pre-approve the facet joint interventions. You say that  the services are medically 
necessary.  The Plan denied your request. The Plan says the facet joint interventions are not medically 
necessary. The Plan says the enrollee has already had two procedures in the lower back in the past 12 months. 
 
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 the facet joint interventions. 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 had two radiofrequency ablation (RFA) procedures in this 
area in the past 12 months. There is a utilization limit of 2 sessions in the same anatomic area in a 12-month 
period. 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 the facet joint interventions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the destruction by neurolytic agent, paravertebral facet joint nerves (64635, 
64636)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and a compression 
sleeve to be provided by an OON provider.  
 
You asked the Plan to pre-approve a compression device and a compression sleeve. You say that you are 
requesting reconsideration of the denied items. The Plan denied your request. The Plan says the items were not 
approved. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compression device and a compression sleeve to be provided by an OON provider.
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 is stable and suitable for 
transfer needing daily physician management. The Plan denied your request. The Plan says the enrollee's 
condition does meet all the requirements. Care is being provided in the current inpatient hospital. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87641, 87651, 87653, and 
87798 rendered on November 3, 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 denied codes 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 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 laboratory report does not 
include documentation to support the rationale of using modifier XU for unusual and non-overlapping services. 
 
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 87481, 87640, 87641, 87651, 87653, and 87798 rendered on November 3, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 13, 2023, billed with 
codes 87471, 87481, 87493, 87500, 87529, 87561, 87563, 87640, 87641, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that this was medically necessary. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel testing for the genes of multiple pathogens 
by nucleic acid that was not billed with a single panel code as required. Based on this information, we decided 
that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the genetic testing provided on April 13, 2023, billed with codes 87471, 87481, 
87493, 87500, 87529, 87561, 87563, 87640, 87641, 87651, 87653, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion drug supplies provided from April 2, 2023, 
through April 8, 2023, billed with code A4222. 
 
You asked the Plan to pay for the infusion supplies as billed. You say that this treatment was medically 
necessary and should be paid.  The Plan denied your request. The Plan says there is no documentation of 
delivery of the items 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 A4222 is infusion supplies for external drug infusion 
pump, per cassette or bag (list drugs separately). 
 
 We find that CPT code A4222 is not supported in the medical record. Specifically, this code is for supplies 
related to an infusion pump. The records show that it was billed for antibiotic infusion. This type of infusion is 
not done through an infusion pump. As such, this is not a valid code for this situation. Based on this 
information, we decided that Medicare rules for coverage of the infusion supplies as billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the infusion drug supplies provided from April 2, 
2023, through April 8, 2023, billed with code A4222.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on April 26, 2023. 
 You asked the Plan to pay for the wound care supplies. You say that the enrollee was at a nursing facility and 
the supplies do not require authorization. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for wound care supplies provided on April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that based upon the second 
opinion from an outside physician we purchased the portable oxygen concentrator out of pocket.  The Plan 
denied your request. The Plan says that there is no indication the enrollee's current oxygen equipment is not 
meeting their medical needs or activities of daily living in or around the home.  
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the portable oxygen concentrator is medically necessary.  Our physician reviewer found the enrollee has active desaturation shown on a 6 minute ambulatory study, 
which is exactly for this purpose, to determine desaturation with activity. The enrollee therefore meets oxygen 
requirements and hence a portable concentrator ambulation given size and portability. The documentation 
supports a portable concentrator. 
 
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 portable oxygen concentrator have been met.  Therefore, we decided that the 
Plan has to pre-approve a portable oxygen concentrator.  
 
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: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for 88189. We decided that the Plan does not have to pay for G0452.  
 
You asked the Plan to pay for procedure codes 88189 and G0452 rendered on March 29, 2023.. You say that 
this should be paid for. The Plan says that the records do not support the services billed. 
 
 We decided that the Plan has to pay for 88189.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 88189 is "Flow 
cytometry, interpretation; 16 or more markers." 
 
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 for CPT 88189. Our reviewer says that there is 
evidence of 16 markers being reviewed. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
88189.  
 
We also decided that the Plan does not have to pay for G0452. 
 
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 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 for G0452. Our reviewer says that although there was 
an interpretation, there is no evidence that it is a separate and distinct procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of G0452 have not been met. Therefore, we decided that the Plan does not have to 
pay for G0452. 
 
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: Favorable

 
We decided that the Plan has to pre-approve Matrion placental membrane. 
 
You asked the Plan to pre-approve the requested services. You say that the membrane provides a superior 
protective barrier. The Plan denied your request. The Plan says that the records do not indicate the enrollee's 
infection has resolved.  
 
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 the requested services. Our physician 
reviewer found that the requested service is indicated for the enrollee's condition. The membrane graft will 
facilitate healing and allow to avoid complication and more complex and expensive surgical procedures. 
Therefore, the requested service 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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve Matrion placental membrane.  
 
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 pre-approve radiofrequency ablation (RFA) of the genicular nerve.  
 
You asked the Plan to pre-approve the requested services. You say that the ablation should provide long-term 
relief of knee pain. The Plan denied your request. The Plan says this procedure is considered experimental.  
 
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 the requested services. Our physician 
reviewer found that The American College of Rheumatology/Arthritis Foundation (2019) Guideline for the 
Management of Osteoarthritis of the Hand, Hip, and Knee (Kolasinski, 2020) states that RFA is conditionally 
recommended for treatment of knee osteoarthritis. The recommendation remains conditional due to the fact that 
although some studies have demonstrated potential analgesic benefits with various ablation techniques, the 
available studies lack a standardized technique and controls were not uniform. There is also a lack of evidence 
showing long-term safety data. The review has determined that the services at issue in this case are 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerve.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on February 7, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would 
have driven to the hospital but you were concerned you might pass out again so an ambulance was called. You 
also say that the ambulance personnel explained that you had anxiety. The Plan denied your request. The Plan 
says these services are not a covered benefit.  
 
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 February 7, 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 response and treatment with no 
transport provided on February 7, 2023.