Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99222, 99232, 93458-26, 
93571-26-LC-59, 99152 and 99239. We decided that the Plan does not have to pay for the services described 
by procedure code(s) 99153.  
 
You asked the Plan to pay for practitioner services provided on September 13, 2023, to September 15, 2023, 
billed with procedure codes 99153, 99222, 99232, 93458-26, 93571-26-LC-59, 99152 and 99239. You say that 
the claim is billed correctly and should be paid. The Plan says that procedure code 99153 is not payable in the 
facility setting. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99222, 99232, 93458-
26, 93571-26-LC-59, 99152 and 99239.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 99222, 99232, 93458-26, 
93571-26-LC-59, 99152 and 99239.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99153. 
 
The Plan follows Medicare rules. Medicare rules say that the outpatient prospective payment system (OPPS) 
recognizes that Current Procedural Terminology (CPT) code 99153 is a practice expense (PE) only code and is 
not payable in the facility setting. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 99153 have not been met. Therefore, we decided that 
the Plan does not have to pay for the services described by procedure code(s) 99153. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Perphenazine. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has been on this medication for 10 
years and is stable on the medication. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Perphenazine.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device.  
 
You asked the Plan to pre-approve the Vertiflex Superion device. You say that the enrollee has suffered from 
their condition for over five years which has greatly impacted their quality of life. You say that the enrollee's 
condition results in the narrowing of the spine causing cramping, pain, tingling, and weakness in the back, 
buttocks, and legs. The Plan denied your request. The Plan says the Vertiflex Superion device 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 Vertiflex Superion device. Our 
reviewer says that the Vertiflex Superion device is not medically necessary. Our physician reviewer found that 
the Vertiflex device is considered experimental in spine surgery.  
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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic resonance imaging, spinal canal (72148) to 
be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says the Plan must pay for 
care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-
approved care, these services are not urgent or emergent, nor were they approved in advance.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 provider at issue in this case is not a network provider with the Plan. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. (Please 
note, items and services received in-network are still subject to any other Medicare coverage rules that apply.) 
We found no exception that would require the Plan to pre-approve an MRI. Therefore, we decided that the Plan 
does not have to pre-approve a Magnetic resonance imaging, spinal canal (72148) to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 10, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted all supporting 
documentation. The Plan denied your request. The Plan says the provider is not enrolled in Medicare as a 
durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on August 10, 2023.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the eye drops received while in the Emergency 
Department on August 1, 2023. 
 
You asked the Plan to hold you harmless for the eye drops. You say that you were not advised that this service 
was not covered. The Plan denied your request. The Plan says that Service is not covered and member was 
notified prior to the service being performed; therefore, member is responsible for charges. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You received the eye drops by a contract provider. The file does not show that the Plan provided notice that the 
eye drops would not be covered. The Plan claims that you were advised that the services were not covered; 
however, no documentation in the case file supports that you were advised of this. Under Medicare rules, this 
means the eye drops is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for the eye drops received while in the Emergency Department on August 1, 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: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 52332 billed for date of service August 2, 
2023.  
 You asked the Plan to pay for procedure code 52332. You say that these services were billed appropriately. 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 52332 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 52332 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 52332 billed for date of service August 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 29, 
2023, to September 9, 2023. 
 
  You asked the Plan to pay for procedure code S9328. You say that the Plan authorized you to provide 
physician-requested patient management services. You also say that you would like this claim to be 
reprocessed for payment. 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 August 29, 2023, to September 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the therapeutic exercises provided by a 
chiropractor on August 31, 2023, to September 7, 2023. 
 
You asked the Plan to pay for the office visit and the therapeutic exercises. You say that the billing code 97110 
is the problem because it does not show the right type of work that was done on your body. The Plan denied 
your request. The Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit and the therapeutic exercises provided by a chiropractor on 
August 31, 2023, to September 7, 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 the enrollee will clearly benefit from acute 
rehabilitation to optimize their level of functioning prior to returning home. The Plan denied your request. The 
Plan says an IRF admission is not medically necessary, and a lower level of care might be appropriate.  
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and 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 the 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PAE. 
 
You asked the Plan to pre-approve PAE. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the criteria for coverage. 
 
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 PAE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that use of the PAE has not been shown to result in sustained long term health benefits in the 
Medicare population with benign prostatic hyperplasia (BPH) as described in this clinical scenario. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PAE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve PAE.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on July 28, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted all supporting 
documentation and are requesting the claim be reprocessed and paid. The Plan denied your request. The Plan 
says the provider is not a plan contract provider and is not enrolled in Medicare as a durable medical equipment 
supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on July 28, 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 you are requesting reconsideration of the 
denied LTACH admission. The Plan denied your request. The Plan says LTACH care 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 the medical records do not support that there are services at an LTACH that are not 
currently available at the acute care hospital where the patient is receiving care. The medical records do not 
support that the physician expects the patient's care to meet or exceed 25 days. Additionally, the medical records do not support that the services could not be obtained at a lower level of care such as a SNF when the 
patient is in a more suitable condition for discharge.  
 
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 pre-approve genetic-testing services (81162).  
You asked the Plan to pre-approve genetic testing. You say that the requested services are a necessity for your 
care. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that coverage eligibility exists when the criteria listed in 
the Medicare rules section have been met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the available medical record does not support that 
you have any cancer diagnosis at this time. Therefore, we decided that the Plan does not have to pre-approve 
genetic-testing services (81162).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) provided on July 22, 
2023. 
 
You asked the Plan to pay for an emergency department visit (99285) provided on July 22, 2023.. You say that 
procedure code 99285 is appropriate based on the services performed. The Plan denied your request. The Plan 
says the records do not support the services at issue 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, 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 an emergency department visit (99285) provided on July 22, 
2023.. Our reviewer says that the service at issue in this case is not supported by the medical records. Our 
reviewer found the enrollee was evaluated in the emergency department (ED) for epigastric pain. The 
documentation supports an appropriate history and physical were documented; However, the medical decision 
making was not of high complexity. 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 an emergency department visit (99285) provided on July 22, 2023. have not 
been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99285) 
provided on July 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0367), and a bone replacement 
graft for ridge preservation (D7953) provided on August 1, 2023, to September 19, 2023. 
 
You asked the Plan to pay for D0367 and D7953. You say that the oral surgeon said that a dental implant is 
necessary. The Plan denied your request. The Plan says the rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam CT capture (D0367), and a bone replacement graft for ridge preservation (D7953) provided on August 1, 
2023, to September 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on June 
06, 2023. 
 
You asked the Plan to waive the copayment for the office visit (99213). You say that the cost share is wrong. 
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 $20 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $20 copayment for the office visit (99213). 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 the office visit (99213) provided on June 06, 2023.