Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and psychiatric evaluation (90792) 
provided on April 19, 2023, to June 08, 2023. 
 
You asked the Plan to pay for the office visit (99214) and psychiatric evaluation (90792). You say that the 
services should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit (99214) 
and psychiatric evaluation (90792) provided on April 19, 2023, to June 08, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of an incompetent vein 
(36478). 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins is covered when specific 
criteria are met. 
 
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 endovenous ablation therapy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does not meet coverage criteria. Coverage criteria require that there be documentation of reflux in the vein 
segments to be treated.  In this case, there is only documentation of reflux immediately around the 
saphenofemoral junctions. It is not documented that there is reflux throughout the veins slated for 
treatment. The documentation, in its current form, suggests that there is a plan for ablation of long segments of 
potentially normal veins.  Additionally, it is not clear that there was a concerted effort at conservative 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy of an incompetent vein (36478).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 7, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
prior to your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service March 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve a panniculectomy. You say that you have tried conservative treatments to 
treat your back pain with little success. You say that you feel that your pain is caused by the mass hanging on 
your stomach. You also say that you get rashes under it as is constantly wet. The Plan denied your request. The 
Plan says there is no documentation of chronic infection or inflammation that is refractory to three months of 
appropriate medical therapy. The documentation does not indicate functional impairment or difficulty walking. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 panniculectomy. Our reviewer says 
that the request for a panniculectomy is not medically necessary. Our reviewer found the record indicates that 
the enrollee has localized adiposity. The record provided does not document the presence of intertrigo 
refractory to conservative treatment or functional impairment. Therefore, the reviewer found that the requested 
panniculectomy is considered cosmetic and 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 a panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 2 power wheelchair with captain chair. 
 
You asked the Plan to pre-approve a Group 2 power wheelchair with captain chair. You say that the enrollee is 
unable to use their lower extremities to control the environment. You say that the enrollee is in need of being 
provided with appropriate technology. The Plan denied your request. The Plan says that the enrollee has not 
had a face-to-face encounter that was conducted within six months prior to the order with a functional mobility 
evaluation form filled out. 
 
The Plan must follow Medicare rules. Medicare rules say that the face-to-face encounter must be conducted 
within six (6) months prior to the order date for the power mobility device. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Group 2 power wheelchair with captain chair have been met. Specifically, the file shows that the 
order was written within six months of the face-to-face evaluation and performed by the same provider. 
Therefore, we decided that the Plan has to pre-approve a Group 2 power wheelchair with captain chair.  
 
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 code 87631 billed for date of service December 
15, 2022.  
 
You asked the Plan to pay for procedure code 87631. You say that this is a distinct test which should be 
separately paid. The Plan denied your request. The Plan says payment for code 87631 is bundled into payment 
for code 87637. 
 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 87631 
is a column II code to column I code 87637 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 code 87631 billed for date of service December 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transport services provided on June 
15, 2023. 
 
You asked the Plan to pay for non-emergent ambulance transport services. You say that the services were 
medically necessary for the enrollee who required transportation by ambulance to and from the nursing home 
to the physician's office. The Plan denied your request. The Plan says the services were not medically 
necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for non-emergent ambulance transport services. 
Our reviewer says that the service was not medically necessary. Our physician reviewer found the 
transportation via ambulance to and from a doctors office for a scheduled appointment was not medically 
necessary. The enrollee did not require the expertise of trained personnel or the equipment available only on an 
ambulance in order to effectuate a safe transport. Transportation could have been provided by other means 
without endangering the enrollees 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 non-emergent ambulance transport services have not been met. Therefore, we 
decided that the Plan does not have to pay for non-emergent ambulance transport services provided on June 15, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service July 5, 2023.  
 You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99285 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. 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 billed for date of service July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultraviolet therapy, infrared therapy, therapeutic injections, 
and platelet-rich plasma (PRP) therapy provided from October 29, 2022, to January 30, 2023. 
 You asked the Plan to pay for outpatient services. You say that you would like the amount of reimbursement 
reevaluated. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 10% coinsurance for out-of-network services obtained through the Plans Point of Service (POS) 
option. The allowed amount of this claim is $493.38, resulting in a coinsurance amount of $49.32. Therefore, 
the Plan issued a reimbursement amount of $444.06. The rules say that platelet-rich plasma is not covered 
outside of chronic non-healing diabetic wounds. 
 
The enrollee has been asked to pay 10% coinsurance for outpatient services. These items/services fall within 
the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Physician/Practitioner Services, 
Including Doctor's Office Visits" benefit categories. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Additionally, the platelet-rich plasma (PRP) is not covered by 
Medicare for the enrollees diagnoses. Therefore, we decided that the Plan does not have to pay for ultraviolet 
therapy, infrared therapy, therapeutic injections, and platelet-rich plasma (PRP) therapy provided from October 
29, 2022, to January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99220) 
rendered on December 29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99220 (1 units) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99220 is "Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee reported no injury, 
incontinence, anesthesia, or weakness, no fever/chills. The examination revealed mild tenderness to the back 
but without other abnormalities. The x-rays revealed multiple chronic right posterior rib fractures without an 
acute fractured noted. The plan included Toradol, antibiotics, fluids, and narcotics. The vitals were stable. 
Although the history and physical were appropriate, the medical decision making was not of high complexity. 
Also, the records did not clearly document that the encounter was 70+ minutes. Therefore, CPT 99220 is not 
sufficiently supported in the provided documentation. 
 
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 evaluation and management services (procedure code 99220) rendered on December 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93229 for date of service November 4, 2022. 
 
You asked the Plan to pay for procedure code 93229. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code 93229 is external mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and 
patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports 
as prescribed by a physician or other qualified health care professional.  
We find that CPT code 93229 is not supported in the medical record. Specifically, the submitted medical 
records do not include a monitoring order which indicates the name of the ordering physician, date and 
Physician Certificate of Medical Necessity. Based on this information, we decided that Medicare rules for 
coverage of procedure code 93229 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 93229 for date of service November 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 13, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
prior to your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service March 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thoracotomy, with biopsy(ies) of pleura rendered on April 
18, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 32098 is "Thoracotomy, with biopsy(ies) of pleura." 
 
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 record does not support that 
32098 is a distinct and separately reportable procedure. The record supports that this is included in the more extensive procedure performed on this date of service and should not be reported separately. 
 
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 thoracotomy, with biopsy(ies) of pleura rendered on April 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service April 23, 
2023, to May 20, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service April 23, 2023, to May 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 for date of service March 
10, 2023. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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 find that CPT codes 83520 and 87798 are not payable as billed. Specifically, the submitted documentation 
did not include a physician order or lab requisition to state what tests were to represent the not otherwise 
specified code billed. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 83520 and 87798 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 83520 and 87798 for date of service March 10, 2023.