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

 
We decided that the Plan does not have to pay for therapeutic, prophylactic, or diagnostic injection (specify 
substance or drug); intravenous push, single or initial substance/drug (96374), therapeutic, prophylactic, or 
diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new 
substance/drug (96375), moderate sedation services (99152) and an Injection, midazolam hydrochloride, per 1 
mg (J2250) provided on March 1, 2023. 
 
You asked the Plan to pay for injections and sedation. You say that you disagree with the denial and ask the 
claim to be processed for additional payment. The Plan denied your request. The Plan says the requested 
services are 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 injections and sedation. Our reviewer says that the service is 
not medically supported. Our reviewer found CPT codes 96374 and 96375 are not supported. According to 
National Correct Coding Initiative (NCCI) and CPT rules, the injections are part of the main procedure and 
cannot be reported separately. The record does not support that these were unrelated and separately identifiable 
injections. Four (4) units of J2250 are not supported. The record states 2 mg was administered, which equals 2 
units, not 4. CPT code 99152 is not supported. The record is missing the required elements of moderate 
sedation reporting, including the start and stop time of the provider at the enrollees bedside and a trained, 
independent observer. Records do not support the services billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections and sedation have not been met. Therefore, we decided that the Plan 
does not have to pay for therapeutic, prophylactic, or diagnostic injection (specify substance or drug); 
intravenous push, single or initial substance/drug (96374), therapeutic, prophylactic, or diagnostic injection 
(specify substance or drug); each additional sequential intravenous push of a new substance/drug (96375), 
moderate sedation services (99152) and an Injection, midazolam hydrochloride, per 1 mg (J2250) provided on 
March 1, 2023.
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 the patient had gamma knife with DR. Loudon 
and would like continued care. 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: 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 the enrollee is stable and suitable for 
transfer to an LTACH.  The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary.  
 
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 the enrollee is improving but still is unstable and only requires short-term acute 
care at the current facility until they are more stable. The enrollee does not require services at the LTACH that 
are not already available at the current facility.  
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) month use of a ventilator (E0466). 
 
You asked the Plan to pre-approve 9-month use of a ventilator. You say that without ventilator therapy, the 
enrollee is at a high risk for hospital readmission and potentially life-threatening exacerbations. The Plan 
denied your request. The Plan says the request for continued use of a ventilator 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 9-month use of a ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease and obstructive 
sleep apnea. Provided records document that the home ventilator is being requested for use in an average 
volume assured pressure support (AVAPS) mode which is a modality that could be provided by a bilevel 
positive airway pressure (BiPAP) device with 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9-month use of a ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nine (9) month use of a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Orthosis. 
 
You asked the Plan to pre-approve the MyoPro Orthosis. You say that the MyoPro Orthosis is registered with 
the Food and Drug Administration (FDA) and medically necessary for this stroke patient. The Plan denied your 
request. The Plan says there is not enough evidence that shows MyoPro is helpful. 
 
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 MyoPro Orthosis. Our reviewer 
says that the requested MyoPro Orthosis is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the current clinical guidelines for adult stroke rehabilitation and recovery 
designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb 
exercise therapies" with unproven benefit in the home environment. Although records from the device manufacturer/vendor argue medical necessity of the requested device, records from the enrollee's actual 
treating provider do not clarify why the requested device is the most appropriate treatment for the enrollee's 
condition. 
 
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 MyoPro Orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro Orthosis.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on January 26, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99285. 
 
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 procedure code 99285. Our reviewer says that the medical records do not support the billing of code 99285. Our reviewer found based on the documentation provided, the 
enrollee had rapid-rate atrial fibrillation, which was successfully treated by emergency medical services (EMS). 
In the emergency department, the enrollee had mild sinus tachycardia without chest pain. The history of present 
illness was problem-focused, and the history was not comprehensive. The medical decision making was not of 
high complexity. The enrollees condition, upon presentation, did not present an immediate threat to life or 
function.  As such, the billing of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on January 26, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 17281 billed for date of service July 21, 2020. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says that the records do not include an interpretation report. 
 
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 17281 is destruction, malignant lesion (e.g., laser surgery, 
electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous 
membrane; lesion diameter 0.6 to 1.0 cm. 
 
We find that CPT code 17281 is supported in the medical record. Specifically, the records document the 
destruction of a squamous cell carcinoma, with a diameter of 0.7 centimeters, was provided. The services were 
performed with a curette on the left jawline. Based on this information, we decided that Medicare rules for 
coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for procedure 
code 17281 billed for date of service July 21, 2020.  
 
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: 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 February 1, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653 and 87798. You say that these 
services were necessary and are supported in the medical record. The Plan denied your request. The Plan says 
these codes are not supported for separate reporting. 
 
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 87150, 87481, 87641, 87653 and 87798 are column II codes to 
column I codes 87500 and/or 87801; however, 87150, 87481, 87641, 87653 and 87798 were each 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 procedure codes 87150, 87481, 87641, 87653 and 87798. 
Our reviewer says that these codes are not supported for separate billing in this case. Our reviewer found the 
laboratory report does not include documentation to support that these services were separate and non-
overlapping with the primary procedures. Modifier XU is not 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 procedure codes 87150, 87481, 87641, 87653 and 87798 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 February 1, 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 you want to return to your prior level of function and 
believe that IRF services will help you do that. The Plan denied your request. The Plan says you do not meet 
the criteria for admission to an IRF. 
 
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 you do 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the basivertebral nerve ablation. 
 
You asked the Plan to pre-approve the basivertebral nerve ablation. You say that the enrollee has extrapolated 
all conservative options available before resulting in this procedure request. The Plan denied your request. The 
Plan says the basivertebral nerve ablation is 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 pre-approve the basivertebral nerve ablation. Our 
reviewer says that the basivertebral nerve ablation is not medically necessary. Our physician reviewer found 
that this procedure is considered experimental and investigational. 
 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 basivertebral nerve ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the basivertebral nerve ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 and supplies. 
 
You asked the Plan to pre-approve a Dexcom G6 and supplies. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Dexcom G6 and supplies. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found coverage criteria for a 
CGM requires insulin use or low blood sugar, these do not appear to be present in this case. It seems as if the 
enrollee wants to monitor their blood sugars more often, and although a CGM would assist them in this regard, 
it does not appear as if the coverage criteria has been met. 
 
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 Dexcom G6 and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G6 and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 14, 2023, billed 
with evaluation and management (EM) code 99285-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99285-25 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 physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on January 14, 2023, billed with evaluation and 
management (EM) code 99285-25.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307) provided on June 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 80307 is not supported in the medical record. Specifically, no lab order was provided 
for the billed service. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307) 
provided on June 8, 2022.
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 the injection. You say that the previous lumbar epidural steroid injections 
worked well for the enrollee and improved their functionality. The Plan denied your request. The Plan says the 
epidural steroid injection is 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 pre-approve the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the prior epidural steroid 
injections are not documented to provide greater than 50 % pain relief. Additionally, the enrollee has not been 
receiving multidisciplinary pain management. Therefore, the request is 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that enrollee is in extreme 
pain and needs this procedure to regain maximum function. The Plan denied your request. The Plan says the 
compression fracture is greater than 12 weeks old based on the onset the enrollee's symptoms. 
 
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 percutaneous vertebral augmentation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is not documentation stating there has been a trial of a brace for 
fracture bracing. There is also no evidence that the fracture is less than 12 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a percutaneous vertebral augmentation.