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

 
We decided that the Plan does not have to pay for procedure code 13101 rendered from May 20, 2023, to May 
23, 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 denied code 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 13101 is "Repair, complex, trunk; 2.6 cm to 7.5 cm" 
 
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 medical records provided 
does not include sufficient documentation to validate that a repair, complex, trunk; 2.6 cm to 7.5 cm was performed on May 20, 2023, therefore this procedure 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 13101 rendered from May 20, 2023, to May 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 6, 2023, to 
February 4, 2023. 
 You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
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 January 6, 2023. The NOA was not received by the Plan until February 21, 
2023. 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 home health services provided 
from January 6, 2023, to February 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman interspinal/interlaminar fusion device 
(22840).  
 
You asked the Plan to pre-approve the Minuteman device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this 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 Minuteman device. Our reviewer 
says that the requested Minuteman device not considered medically reasonable and necessary in this case. Our physician reviewer found the HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft 
material and is not intended for stand-alone use. In addition, there are multiple alternate pain generators 
plausibly significantly contributing to the clinical condition that have not been fully documented as having 
been excluded and/or ruled out. No compelling rationale is presented, or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Minuteman 
interspinal/interlaminar fusion device is 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 the Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Minuteman interspinal/interlaminar fusion device (22840).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit (99204) provided on April 14, 2023. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that records do not support the code 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 99204 is an office or other outpatient visit for the evaluation and management of a new patient, which 
requires a medically appropriate history and/or examination and moderate level of medical decision making or 
must reach 45-59 minutes of total time. 
 
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 office visit. Our reviewer says that the documentation 
supports the code billed. Our reviewer found while there is no documentation of 45-59 minutes of total time 
spent, the records support moderate level medical decision-making. 
 
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 office visit have been met. Therefore, we decided that the Plan has to pay 
for an office visit (99204) provided on April 14, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eighty-two (82) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional transportation trips. You say that you need additional 
transportation for your dialysis appointments three times a week. The Plan denied your request. The Plan says 
you have exhausted the maximum benefit of 48 one-way trips per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve eighty-two (82) additional routine transportation trips 
(A0120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuroplasty and/or transposition ulnar nerve wrist 
(64719) and tendon sheath incision (26055) at a hospital site of service. 
 
You asked the Plan to pre-approve neuroplasty and/or transposition ulnar nerve wrist and tendon sheath 
incision at a hospital site of service. You say that this is medically necessary. The Plan denied your request. 
The Plan says as no extenuating medical circumstances such as underlying cardiac or pulmonary conditions 
that may complicate anesthesia or recovery are noted, nor is there evidence of a lack of equipment at the 
ambulatory care center for the outpatient surgery, medical necessity for hospital site of service is not met. 
 
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 neuroplasty and/or transposition ulnar 
nerve wrist and tendon sheath incision at a hospital site of service. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found detailed documentation is not evident regarding a significant past and/or current medical history that 
would place this enrollee at increased risk for peri-surgical complications requiring a hospital. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuroplasty and/or transposition ulnar nerve wrist and tendon sheath incision at 
a hospital site of service have not been met. Therefore, we decided that the Plan does not have to pre-approve 
neuroplasty and/or transposition ulnar nerve wrist (64719) and tendon sheath incision (26055) at a hospital site 
of service.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 for date of service May 27, 2023. 
 
You asked the Plan to pay for procedure code 99222. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that J96.90 has an Excludes1 note in relation to R06.00. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for procedure code 99222 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99222 for date of service May 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lipid panel provided on April 25, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the lipid panel. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service 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 the lipid panel provided on April 25, 2023, by an 
OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee replacement (27447). 
 
You asked the Plan to pre-approve a knee replacement. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria. There is no radiograph showing arthritic 
changes. 
 
The Plan follows Medicare rules. Medicare rules say that knee replacement 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 a knee replacement. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is 
not evident regarding formal diagnostic imaging studies that support advanced degenerative changes. The 
radiographic images noted on the April 22, 2021, examination was not dated and not specific for the right knee. 
Additionally, detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. The provided examinations did not evidence significant 
interference in her activities of daily living. Failure of previous osteotomy; or distal femur fracture; or 
malignancy of the distal femur, proximal tibia, knee joint, or adjacent soft tissues; or failure of previous 
unicompartmental knee replacement; or avascular necrosis of the knee; or proximal tibia fracture are not 
evident. 
 
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 knee replacement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee replacement (27447).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft, morselized, or placement of osteopromotive 
material, for spine surgery only (20930) and arthrodesis, posterior or posterolateral technique, single 
interspace; lumbar (22612). 
 
You asked the Plan to pre-approve the MinuteMan inter-spinous spacer and fusion device. You say that the 
procedure is medically necessary. The Plan denied your request. The Plan says evidence-based medical 
guidelines and peer-reviewed literature do not support the interspinous fusion device procedure over other 
standard treatments such as lumbar fusion. 
 
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 MinuteMan inter-spinous spacer 
and fusion device. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found there is a lack of large-volume, long-term peer-
reviewed outcome studies to support the use of this device for your medical condition. According to the Food 
and Drug Administration (FDA), The Minuteman G3-R MIS Fusion Plate is a posterior, non-pedicle 
supplemental fixation device, intended for use at a single level in the non-cervical spine (T1-S1). The 
Minuteman G3-R MIS Fusion Plate is intended for use with bone graft material and is not intended for stand-
alone use. In addition, fusion indications within guidelines/literature for (existing or potential intraoperative) 
instability have not been documented and/or met in this case. In addition, there are multiple alternate pain 
generators plausibly significantly contributing to the clinical condition that have not been fully documented as 
having been excluded and/or ruled out. No compelling rationale is presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested Minuteman 
interspinous spacer and fusion device with bone graft material at L3-4 is 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 the MinuteMan inter-spinous spacer and fusion device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve allograft, morselized, or placement of 
osteopromotive material, for spine surgery only (20930) and arthrodesis, posterior or posterolateral technique, 
single interspace; lumbar (22612).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (procedure code 99223) rendered on March 28, 
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 denied code 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 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 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 the provided records in this case 
document an extensive number of diagnoses (upper gastrointestinal hemorrhage, anemia, atrial fibrillation with 
rapid ventricular response, chronic obstructive pulmonary disease and hypothyroidism) and a high risk of 
complication (82-year-old patient with gastrointestinal hemorrhage, hemoglobin of 6.5, heart rate in the 120s 
on anticoagulation with an INR of 1.5). The records do support a high level of medical decision making, as 
well as a medically appropriate history and/or examination. 
 
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 
initial hospital care (procedure code 99223) rendered on March 28, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99232) rendered 
from April 25, 2023, to April 26, 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 Current Procedural Terminology (CPT) code 99232 (1 Unit) 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 99232 is "Subsequent 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 moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded." 
 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 records do not support this 
level of coding. The provided records in this case do not document requires 2 out of 3 of multiple diagnoses or 
management options, a moderate amount and complexity of data reviewed and a moderate risk of complication. 
The records do not support a moderate level of medical decision making. 
 
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 subsequent hospital care (procedure code 99232) rendered from April 25, 2023, to April 26, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home ventilator (E0466). 
 You asked the Plan to pre-approve the home ventilator. You say that you cannot go home until the BiPAP 
machine is received in your home. You say that if you struggle breathing at all, the machine is the only thing 
you can use. You also say that you need to have the machine at home as soon as possible. The Plan denied your 
request. The Plan says your doctor has prescribed a ventilator to help your breathing at various times of the day 
(night and day) because of your lung disease. The Plan also says that Medicare does not cover ventilators used 
in this way. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home ventilator. Our reviewer says 
that the requested home ventilator is not medically necessary. Our physician reviewer found the provided 
documentation supports that you have been diagnosed with chronic obstructive pulmonary disease (COPD) and 
chronic respiratory failure. The documentation indicates you improved with bi-level positive airway pressure 
(BiPAP) therapy in hospital. The documentation does not support BiPAP failure or escalation of therapy. 
Therefore, the reviewer found that the requested home ventilator is 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bone Morphogenetic Proteins (BMP) - Infuse 
Allograft. 
 
You asked the Plan to pre-approve an Infuse Allograft. You say that there is limited published, large-scale, 
long-term peer-reviewed literature that shows this requested allograft to be an effective and/or safe treatment.  
The Plan denied your request. The Plan says this service is 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 an Infuse Allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that BMP is only Food and Drug Administration (FDA) approved for use in the 
anterior lumbar spine. Additionally, iliac crest bone graft is the gold standard of care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Infuse Allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Bone Morphogenetic Proteins (BMP) - Infuse Allograft.