Persius/hicric huggingface dataset:
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has a history of an above the knee amputation and is living at home.  Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 waive the copayment for an out-of-network specialist visit provided 
on February 24, 2023. 
 
You asked the Plan to waive the copayment for an out-of-network specialist visit. You say that you were told 
this provider was in-network, and you should not have to pay more because they are not. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $60 copayment for an out-of-network specialist visit. This item/service falls 
within the physician/practitioner services, including doctors office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an out-of-network specialist visit provided on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99252 and 99253 billed for date of service 
January 13, 2023. 
 
You asked the Plan to pay for procedure codes 99252 and 99253. The Plan denied your request. The Plan says 
the billed codes are 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 codes 99252 and 99253 have a Status Indicator of I on the Physician Fee Schedule. This means that procedure codes 99252 and 99253 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99252 and 99253 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99252 and 99253 billed for 
date of service January 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided on May 29, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of NMES to treat muscle atrophy is limited 
to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and 
peripheral nerves, and other non-neurological reasons for disuse atrophy. Some examples would be casting or 
splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery. 
 
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 TENS device. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is not any documentation of diffuse 
muscle atrophy where nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, 
or other non-neurological reasons for diffuse atrophy. 
 
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 TENS device have not been met. Therefore, we decided that the Plan does 
not have to pay for the transcutaneous electrical nerve stimulation (TENS) device (E0730) provided on May 
29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service July 23, 2022, to 
August 21, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 23, 2022. The NOA was not received by the Plan until November 3, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for 
date of service July 23, 2022, to August 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71271 billed for date of service October 18, 
2022.  
 You asked the Plan to pay for procedure code 71271. You say that the claim should be paid. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 71271 is one (1). The MAI value for this code is 2. You billed two (2) 
units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage 
of procedure code 71271 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 71271 billed for date of service October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning (procedure code 99497) rendered on 
April 6, 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 99497 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 99497 is Advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate. 
 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 there is no clear documentation 
that there was explanation and discussion of advance directives such as standard forms with completion of such 
forms by the medical provider. Therefore, the use of CPT 99497 is not justified. 
 
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 advance care planning (procedure code 99497) rendered on April 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64450 and 76942 billed for date of service 
October 4, 2022. 
 You asked the Plan to pay for procedure codes 64450 and 76942. You say that these services were necessary 
and were reported appropriately. The Plan denied your request. The Plan says these services are not supported 
for reporting in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 64450 is a column II code to column I code 01230; however, 64450 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 64450 and 76942. Our reviewer says that 
these codes are not supported in the medical record. Our reviewer found the criteria for separate payment of 
codes 64450-59 and 64450-59-51 are not met in this case. Postoperative pain management services are 
generally provided by the surgeon who is reimbursed under a global payment policy related to the procedure 
and shall not be reported by the anesthesia practitioner unless separate, medically necessary services are 
required that cannot be rendered by the surgeon. The surgeon is responsible for documenting in the medical 
record the reason that care is being referred to the anesthesia practitioner. In addition, code 76942 is not 
supported in the medical record. The procedure report does not include documentation of ultrasonic guidance 
for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and 
interpretation. The report cannot be cited as this procedure was not found in documentation and therefore 
cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 64450 and 76942 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 64450 and 76942 billed for date of service October 4, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93306 for date of service April 19, 2023. 
 
You asked the Plan to pay for procedure code 93306. 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 93306 is echocardiography, transthoracic, real-time with 
image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler 
echocardiography, and with color flow Doppler echocardiography. 
 
We find that CPT code 93306 is not supported in the medical record. Specifically, the documentation does not 
support that echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode 
recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography branch was performed. There is a more appropriate code to be billed for the services 
provided. Based on this information, we decided that Medicare rules for coverage of procedure code 93306 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 93306 for date 
of service April 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Botox injection rendered on October 27, 2022. 
 
You asked the Plan to pay for the injection. You say that you submitted medical records for review. The Plan 
denied your request. The Plan says this is not a Medicare benefit for the diagnoses documented in the clinical 
record. 
 The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 injection. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
the record indicates that the enrollee has a diagnosis of anal spasm. The Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's described condition. The Medicare approved  drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's described 
clinical situation. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for a Botox injection rendered on October 27, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76498 rendered on April 2, 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 that the records do not contain a ultrasound 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 76498 is "Unlisted magnetic resonance procedure (eg, diagnostic, interventional)." 
 
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 supported by the medical records. Our reviewer found that CPT 76498 is an unlisted magnetic 
resonance imaging (MRI) procedure. Commonly this is used for fusion ultrasound and MRI for biopsy 
purposes. The unlisted procedure in this particular case was reasonable since a whole body MRI with the 
diagnosis of Schwannomatosis (multiple Schwannomas) is a condition which is associated with tumors of 
multiple organ systems and since a whole body MRI has no specific CPT code the use of an unlisted procedure, 
in this case 76498, was reasonable and did not require the typical ultrasound usually associated.   
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 76498 rendered on April 2, 2023.  
 
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: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 22830. We decided that the Plan does not have to pay for 20930 and 
20936.  
 
You asked the Plan to pay for procedure codes 20930, 20936, and 22830 rendered on February 22, 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 22830.  
 
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 CPT 22830 - exploration of spinal fusion. Our 
reviewer says that that the records support the use of CPT 22830. Our physician reviewer found that the 
procedure details cite the previous hardware was carefully removed without incident. The fusion mass over the 
L3-4 region was carefully explored and was noted to have decent fusion at that particular area. Therefore, the 
records do support that CPT 22830: exploration of spinal fusion was rendered in this case.  
 
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 
22830.  
 
We also decided that the Plan does not have to pay for 20930 and 20936. 
 
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 the upheld codes is: 
 
CPT 20930: 
 
Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in 
addition to code for primary procedure) 
 
CPT 20936: 
 
Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar 
fragments) obtained from same incision (List separately in addition to code for primary procedure) 
 
We find that these procedure codes have status indicator of B on the Physician Fee Schedule. This means that 
these codes not separately payable. Based on this information, we decided that Medicare rules for coverage of 
20930 and 20936 have not been met. Therefore, we decided that the Plan does not have to pay for 20930 and 
20936. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76937 billed for date of service November 
15, 2022. 
 
You asked the Plan to pay for procedure code 76937. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says this code is not supported in the medical record. 
 
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 76937 is ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
real time ultrasound visualization of vascular needle entry with permanent recording and reporting (List 
separately in addition to code for primary procedure). 
 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 76937. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the procedure report does not include documentation 
of a service which could be described with this code. 
 
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 76937 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 76937 billed for date of service November 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 18, 2022, to 
August 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 18, 2022, to August 
5, 2022.  
 
Please note that this decision is limited to the original claim denial.  If you have questions regarding the 
submission of a corrected claim, you will need to send those questions to the Plan directly.