Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 2, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with diagnosis codes M54.2 and 
M50.31. Diagnosis code M54.2 has an Excludes1 note and cannot be billed with diagnosis code M50.31. 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 the services provided on February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93228 and 93229 billed for date of service 
January 17, 2023. 
 
You asked the Plan to pay for procedure codes 93228 and 93229. You say that these services were reported 
appropriately. The Plan denied your request. The Plan says these services are not supported in the medical 
records. 
 
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 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 93228 and 93229. Our reviewer says that 
these codes are not supported in the medical record. Our reviewer found the documentation submitted does not 
include enough documentation to confirm that the criteria for these codes are met. 
 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 93228 and 93229 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 93228 and 93229 billed for date of service January 17, 
2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing services (G0483) provided on October 24, 2022. 
 
You asked the Plan to pay for drug testing services. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says that the date of service billed 
does not align with the date on the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that with limited exceptions, laboratory services should generally be reported with the date of 
specimen collection as the date of service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of drug testing services have been met. Specifically, this claim was submitted with a date of service 
of October 24, 2022. The records provided support that the specimen for this testing was obtained on October 
24, 2022. There is no evidence that any of the exceptions to the general rule are met in this case, so the date of 
specimen collection is appropriate to report these services. Therefore, we decided that the Plan has to pay for 
drug testing services (G0483) provided on October 24, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture  mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the requested service to be 
covered by your insurance. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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. This benefit includes the 
requested D5120 but is limited to one per 60 floating months. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered complete denture  mandibular (D5120) on September 10, 2021. Therefore, this 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve complete denture 
 mandibular (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office or other outpatient consultation for a new or 
established patient (99244). 
 
You asked the Plan to pre-approve an office visit. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the CPT code that the provider requested for an 
office visit is not covered by Medicare or the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99244 is no longer recognized by Medicare. Specifically, for this visit to be approved, 
the provider should send a valid CPT code that is covered by Medicare. Based on this information, we decided 
that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an office or other outpatient consultation for a new or established patient (99244).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has kidney and heart problems, and the 
SNF care should be covered. The Plan denied your request. The Plan says the enrollee's benefit has been 
exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from December 12, 
2022, to May 1, 2023. The Plan has covered 100 days of SNF care.  
 
 
  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service October 29, 2022. 
 
You asked the Plan to pay for code 99285. You say that code 99285 was billed correctly. The Plan denied your 
request. The Plan says code 99285 is not supported by the medical records. As a result, the claim was down-
coded and paid at the 99284 rate. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 code 99285 Our reviewer says that code 
99285 is not supported by the medical record. Our reviewer found the member is a 67-year-old male with a 
medical history including hypertension who was evaluated and treated in the emergency department on 
October 29, 2022. The documentation indicates the member presented with shortness of breath and was 
evaluated for various etiologies including bronchitis and a possible pulmonary embolism. He remained 
medically stable and the diagnostic testing was unremarkable. He was treated for bronchitis and discharged 
home the same day. The documentation available for review does not support that the presenting problems 
were of high severity or that the medical decision was of high complexity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service October 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthopedic services (99213, 20610, J1030) provided on 
January 24, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for orthopedic services. You say that the enrollee was previously seen by this 
provider and was not aware their insurance had changed. 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 orthopedic services (99213, 20610, J1030) 
provided on January 24, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on February 6, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for physical therapy services. You say that these services do not require 
authorization. The Plan denied your request. The Plan says out-of-network services require authorization. 
 
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 physical therapy services provided on February 6, 
2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. The Plan denied your request. The Plan says this 
service is considered experimental and/or unproven.  
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the CardioMEMS device was approved by the Food and Drug Administration 
(FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of 
pulmonary artery pressure in the management of patients with congestive heart failure (CHF). The clinical 
study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved 
ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and 
suggest an improvement in heart failure symptoms with the use of the device. In addition, published expert 
opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there 
remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not 
be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
January 31, 2023. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that home health services are a 
covered benefit and you have provided medical records to support medical necessity. 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 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve a continuation of care with an OON provider. You say that you have been 
seeing the provider for years and they have a good relationship.  The Plan denied your request. The Plan says 
the OON provider is not uniquely qualified to treat the enrollee's condition.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of care with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met.  Our physician 
reviewer found the OON provider is not more qualified or more appropriate for treating the enrollee's Multiple 
Sclerosis than the network providers being offered. The enrollee's medical management can safely be transition 
to an in-network specialist at this time.  
 
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 continuation of care with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 more home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that you are having a hard time getting 
around your home and cannot go to the physical therapist's office. The Plan denied your request. The Plan says 
the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not support that you require additional skilled rehabilitation services to provide treatment 
that is medically necessary. You do not require additional skilled rehabilitation services to effectively provide 
treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain 
your condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 3 more home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytopathology services (88141) provided on December 12, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for out-of-network cytopathology. You say that these services were referred by a 
plan provider. The Plan denied your request. The Plan says these services were not performed or referred by a 
network provider. Out-of-network care is covered only in certain limited circumstances which have not been 
met in this case. 
 
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 or referred 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 cytopathology services (88141) 
provided on December 12, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43753 billed for date of service December 
20, 2022. 
 
You asked the Plan to pay for procedure code 43753. You say that this service is supported in the medical 
record and should be paid. The Plan denied your request. The Plan says the payment for this service is included 
in the global surgery payment for code 23500, which was performed on November 28, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that postoperative payment rules apply to code 
23500, which is classified as a major surgery and has a global surgery period of 90 days. Modifiers are 
necessary to report an unrelated service or procedure by the same physician during a postoperative period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 43753 have not been met. Specifically, both claims in this case report the same 
rendering physician. Procedure 23500 was provided to this enrollee on November 28, 2022, and has a global 
surgery period of 90 days. Procedure 43753 was performed within this 90-day period and was not billed with a 
modifier to identify it as an unrelated service. Therefore, we decided that the Plan does not have to pay for 
procedure code 43753 billed for date of service December 20, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve behavioral health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON behavioral health services. You say that you have received services 
with the provider at issue and would like to continue. The Plan denied your request. The Plan says rules for 
coverage for OON services have not been met. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 OON behavioral health services. Our 
reviewer says that OON behavioral health services are not medically reasonable and necessary in this case. Our 
physician reviewer found that the only reason for seeing an out-of-network provider is in urgent/emergent 
condition or if a therapist is not available in network. Based on review of the records provided, you do not 
require treatment by an out-of-network provider as the medical plan is able to provide a provider for the 
treatment of your condition. Your condition is not considered urgent/emergent condition. Utilization of 
network providers assures a credentialed and clinically maintained individual assured by the medical provider 
to a certain 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 OON behavioral health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve behavioral health services to be provided by an out-of-network (OON) 
provider.