Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S0020, 64636, and J2001 billed for date of 
service December 16, 2022. 
 
You asked the Plan to pay for procedure codes S0020, 64636, and J2001. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the codes are not payable as 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, we have confirmed that code 64636 is a column II code to column I code 64625. We have confirmed that code J2001 is a column II code to column I code 27096. This claim has not been billed with an appropriate modifier to bypass the edit. 

We find that procedure code S0020 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure 
code S0020 is not valid for Medicare purposes. 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 codes S0020, 64636, and 
J2001 billed for date of service December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on March 28, 2023. 
 
  You asked the Plan to pay for initial hospital care (99223). You say that the provider should not be penalized 
for providing services that were medically necessary and the claim should be processed for payment. The Plan 
denied your request. The Plan says the services were billed with an inappropriate Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services. POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the claim was billed with 
POS code 21. However, the documentation shows that the enrollee was in observation status. Observation is an 
outpatient status, so POS code 22 should have been billed on the claim. Based on this information, we decided 
that Medicare rules for coverage of initial hospital care (99223) provided on March 28, 2023. have not been 
met. Therefore, we decided that the Plan does not have to pay for initial hospital care (99223) provided on 
March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring Device (K1024 and K1025).  
 
You asked the Plan to pre-approve a Koya Dayspring Device. You say that the items are medically necessary. 
The Plan denied your request. The Plan says this is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Koya Dayspring Device. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental. 
 
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 Koya Dayspring Device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Koya Dayspring Device (K1024 and K1025).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
LTACH services due to current medical management necessity and prolonged hospitalization. The Plan denied 
your request. The Plan says the LTACH services requested do not meet the requirements for approval.  
 
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 enrollee is improving but still requires acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services and these have not 
been denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T4 kyphoplasty (22513, 77002). 
 
You asked the Plan to pre-approve T4 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of kyphoplasty in the setting of multiple 
etiologies for pain seen on imaging, have not been demonstrated in the peer-reviewed literature. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 T4 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding worsening pain. There is no indication of a progression of the body height loss, kyphotic 
deformity, or a severe impact on daily activities. Moreover, there is magnetic resonance imaging corroboration 
of other plausible causes of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T4 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve T4 kyphoplasty (22513, 77002).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for federally qualified health center (fqhc) visit provided on 
October 28, 2022. 
 
You asked the Plan to pay for federally qualified health center (fqhc) visit. 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 federally qualified 
health center (fqhc) visit provided on October 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).  
 
You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator . 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 an ultrasonic osteogenesis stimulator will be denied 
as not medically necessary if any of the coverage criteria listed in the Medicare Rules section are not 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 an ultrasonic osteogenesis stimulator. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found radiographs 
including three views of the left foot and ankle show appropriate alignment of the enrollee's revision triple 
arthrodesis with no hardware complication or failure noted.  
 
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 ultrasonic osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare part B prescription drugs and 
dialysis treatment provided on January 4, 2023, to January 30, 2023. 
 
You asked the Plan to waive the cost share for Medicare part B prescription drugs and dialysis treatment. You 
say that you disagree with the cost share 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% 
coinsurance for Medicare part B prescription drugs, a 20% coinsurance for services to treat kidney disease/ dialysis treatment and a $800 out-of-pocket maximum.  
 
You have been asked to pay a 20% coinsurance Medicare part B prescription drugs, a 20% coinsurance for 
dialysis treatment and a $800 out-of-pocket maximum. The total allowed amount for all services rendered is 
$4,035.40 you are being asked to pay is $807.08 ($4,035.40 x 20% = $807.08). However, your out-of-pocket 
maximum is $800 therefore you are only responsible for your $800 out of pocket maximum. This item/service 
falls within the Medicare part B prescription drugs and services to treat kidney disease/ dialysis treatment 
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 cost share for Medicare part B prescription 
drugs and dialysis treatment provided on January 4, 2023, to January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on April 5, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. The Plan denied your request. The Plan says this was not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a nursing facility visit provided on April 5, 2023, 
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 ambulatory infusion pump (E0781) provided March 27, 
2023. 
 
You asked the Plan to pay for the ambulatory infusion pump. You say that the ambulatory infusion pump and 
infusion supplies are medically necessary in the administration of the enrollees chemotherapy treatment as 
prescribed by the doctor. The Plan denied your request. The Plan says the claim was billed without the 
appropriate capped rental modifier that correctly identifies the month of rental.  
 
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 find that CPT code E0781 is not supported in the medical record. Specifically, the claim was 
not billed with the appropriate capped rental modifier that correctly identifies the month of rental. A corrected 
claim must be submitted. Based on this information, we decided that Medicare rules for coverage of the 
ambulatory infusion pump have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulatory infusion pump (E0781) provided March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation with medical services 
provided on January 17, 2023. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation with medical services. 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 psychiatric diagnostic 
evaluation with medical services provided on January 17, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that that the enrollee is 73 years old, and it is hard for 
them to make the 50-minute commute 5 times to the office. You say that if the enrollee gets Injectafer it would 
limit the number of visits down to 2.  The Plan denied your request. The Plan says that the step therapy 
requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that 
Injectafer is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's required drug Venofer. Also, there is no indication that the Plan's required drug would likely be less 
effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99233 and 99223 billed for December 16, 
2022, to December 18, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 99233 and 99223 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 99233 is Level 3 subsequent hospital care for evaluation 
and management of patient, including detailed interval history and medical decision making of moderate 
complexity, typical time 35 minutes. The definition of code 99223 is Level 3 initial hospital care for evaluation 
and management of patient with problem of high severity, including comprehensive history and physical 
examination, and medical decision-making of high complexity, typical time 70 minutes. 
 
We find that CPT codes 99233 and 99223 are not supported in the medical record. Specifically, there is no 
evaluation and management note to support either code for the billed dates of service. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99233 and 99223 billed for December 16, 2022, 
to December 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve the dental services. You say that you are in a great deal of pain, and you 
have no way to address this issue if insurance will not cover it. The Plan denied your request. The Plan says the 
service is purely dental in nature and cannot be covered under the medical plan. The Plan also says the service 
is not covered under your dental plan. 
 
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. The requested service is also not eligible for coverage under the 
medical benefit. Therefore, we decided that the Plan does not have to pre-approve an incisional biopsy of oral 
tissue (D7286).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for each office visit provided on November 16, 2022, to 
February 08, 2023. 
 
You asked the Plan to pay for each office visit. You say that the services were medically necessary. 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 each office visit 
provided on November 16, 2022, to February 08, 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 requires 24 hour nursing care and daily 
physician oversight. The Plan denied your request. The Plan says the enrollee does not meet all of the 
requirements. Services needed may be provided safely in a lower level of care. 
 
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. 
 
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: Favorable

 
We decided that the Plan has to pay for procedure code 96366 billed for date of service December 12, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee received infusions. The Plan denied 
your request. The Plan says that the record did not support the number of units 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 96366 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary 
procedure). 
 
We find that CPT code 96366 is supported in the medical record. The records show that intravenous therapy 
started at thirteen twenty-two (13:22) and ended at fifteen twenty-eight (15:28), indicating 2 hours of treatment. 
The first hour, identified by code 96365 was billed and paid for by the Plan. 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 96366 billed for date of service December 12, 2022.  
 
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.