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

 
We decided that the Plan does not have to pre-approve arthrodesis, anterior instrumentation, an allograft, and 
an inpatient stay. 
 
You asked the Plan to pre-approve arthrodesis, anterior instrumentation, an allograft, and an inpatient stay. You 
say that physical therapy is inappropriate in this case and would not help her condition. The Plan denied your 
request. The Plan says the enrollee has not tried conservative therapy. 
 
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 arthrodesis, anterior instrumentation, an 
allograft, and an inpatient stay. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the provided magnetic 
resonance imaging (MRI) does not corroborate any significant changes from the previous MRI from October 8, 2021. There are limited large-scale, long-term references showing the safety and efficacy of the requested 
surgery in this clinical setting. No compelling rationale is presented, or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested anterior cervical 
discectomy and fusion at C3-6 with an inpatient stay 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 arthrodesis, anterior instrumentation, an allograft, and an inpatient stay have not 
been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis, anterior 
instrumentation, an allograft, and an inpatient stay.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (procedure code 99233) rendered on August 16, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code 99233 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 99233 is "Subsequent hospital care, per day, for the evaluation and management of a patient, which 
requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical 
decision making of high complexity. Counseling and/or coordination of care with other physicians, other 
qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and 
the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication 
or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the documentation does reflect a 
comprehensive history, a comprehensive exam, and medical decision making of high complexity, and at least 
35 minutes spent at the bedside and on the enrollee's unit. 
 
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 99233) rendered on August 16, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service November 3, 
2022. 
 You asked the Plan to pay for procedure code 87634. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this code is not supported for separate 
payment. 
 
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 87634 is a column II code to column I code 87798; however, 87634 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 87634. Our reviewer says that code 87634 is 
not supported for separate reporting and payment. Our reviewer found there is no documentation that CPT code 
87634 was distinct from CPT code 87798. Provided records in this case do not document that the tests were 
separate and distinct procedures or services; the records document that a single swab specimen was obtained at 
a single point in time and tested in a single procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87634 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87634 billed for date of service November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 17, 2023. 
 
You asked the Plan to pay for an office 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 an office visit provided 
on January 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 52005 and 76000 rendered on February 21, 
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 records do not support the services 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 the denied codes is: 
 
CPT 52005: 
 
Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service 
 
CPT 76000: 
 
Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT code 76000 is not supported. 
The fluoroscopy is included in cystourethroscopy and ureteroscopy and is not separately reportable. CPT code 
52005 is not supported as a separately identifiable procedure. The ureteral catheterization is an integral part of 
the treatment of ureteral stricture reported with 52344 and should not be reported separately. 
 
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 codes 52005 and 76000 rendered on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided from October 28, 2021, 
to January 25, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the psychotherapy services. You say that this is supported in the records. The 
Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 
items/services 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 psychotherapy services provided from October 
28, 2021, to January 25, 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 practitioner services provided on August 10, 2022, billed 
with procedure code 01402-QZ (165 units). 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says records do not support the service 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 01402-QZ is Anesthesia for open or surgical arthroscopic 
procedures on knee joint; total knee arthroplasty. 
 
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 practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that in this case, the claim denied correctly 
as units billed are not supported in the procedure report. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 10, 2022, billed with procedure code 
01402-QZ (165 units).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service 
March 16, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says the billed services cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that the enrollee received intravenous insulin therapy in an outpatient setting. We find that CPT 
code 96365 and 96366 is not supported. There is a more accurate code to describe the services provided. The 
rules also say that the services in question do not improve health outcomes. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 24, 2023. 
 
You asked the Plan to pay for an office 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 an office visit provided 
on February 24, 2023.
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 services are medically necessary. The Plan 
denied your request. The Plan says you do not have daily skilled therapy or nursing needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that inpatient therapy goals have been met. This 
would not be expected to require continued daily skilled therapy. Clinical documentation does not specify any 
daily skilled nursing needs. This does not support continued daily skilled services. The clinical documentation 
does not support continued daily skilled services on an inpatient basis in a skilled nursing 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 SNF care have not been met. 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 an office visit provided on March 29, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 an office visit provided 
on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasounds and an office visit provided on February 09, 
2023. 
 
You asked the Plan to pay for the ultrasounds and an office visit. You say that you are requesting 
reconsideration of the denied claim. 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 the ultrasounds and an 
office visit provided on February 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E1007, E1012, E2311, E2313, E2377, 
E2361, and E2607). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the power wheelchair with tilt and recline is medically necessary for the enrollee. The Plan denied 
your request. The Plan says the enrollee does not have medical need for multiple power options included with 
K0861 group 3 power wheelchair. The Plan also says the electronic connection, harness, and expandable 
controller cannot be covered as it is not medically necessary to control the three requested power options 
through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rule section of this letter 
are met. Medicare rules also say if the PWC base is not covered, then related accessories will be denied. 
 
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 group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the coverage criteria for 
the requested group 3 power wheelchair. Our physician reviewer found the enrollee has heart failure, COPD, 
diabetic neuropathy and morbid obesity. The enrollee does not have high risk for skin breakdown, use a 
catheter intermittently, have spasticity or require an alternative means of managing power drive. Our reviewer 
also found that the enrollee does not require tilt or tilt and recline power drives. 
 
 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 group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E1007, E1012, 
E2311, E2313, E2377, E2361, and E2607).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with DRG 871 rendered 
from June 2, 2022, to June 4, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the review results in a change from DRG 871 
to DRG 178. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that based on the medical records provided, DRG 178 most accurately reflects the enrollee's condition and 
treatment in this case. There is no documentation that fully supports diagnosis code A41.9. The provided 
records in this case do not document life threatening multi-system organ dysfunction related to infection to 
meet criteria for sepsis, A41.9. The treating physician in the emergency department (ED) reported the patient 
was "stable in the ED" with no significant hypoxemia, no respiratory distress except tachypnea and overall 
findings consistent with aspiration pneumonia and no mention of sepsis. The hospitalist's assessment reported 
the enrollee was awake and alert with normal affect and the admitting diagnosis was mutifocal pneumonia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with DRG 871 rendered from June 2, 2022, to June 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
August 04, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you do not agree with 
the copayment. 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 $100 
copayment for outpatient hospital services. 
 
You have been asked to pay a $100 copayment for outpatient hospital services. This item/service falls within 
the outpatient hospital services 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 
outpatient hospital services provided on August 04, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 08, 2023. 
 
You asked the Plan to pay for laboratory 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 laboratory services 
provided on January 08, 2023.