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

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
April 29, 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 Current Procedural Terminology (CPT) code 99223-57 (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. 
 
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 documentation does not 
reflect a comprehensive history, exam, or medical decision making of high complexity. 
 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 initial hospital care (procedure code 99223) rendered on April 29, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 17 additional fractions of intensity modulated radiation therapy 
(IMRT). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the use of 45 fractions of IMRT is 
considered acceptable by the National Comprehensive Cancer Network (NCCN), American Society for 
Radiation Oncology (ASTRO), and American Urological Association (AUA) guidelines for the treatment of 
intermediate risk prostate cancer. The additional 17 fractions of IMRT are therefore reasonable and medically 
necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve 17 additional fractions of intensity modulated radiation therapy (IMRT).  
 
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 87150 billed for date of service November 
28, 2022. 
 You asked the Plan to pay for procedure code 87150. The Plan denied your request. The Plan says payment for 
code 87150 is bundled into payment for code 87500. 
 
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 87150 
is a column II code to column I code 87500. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 87150 billed for date of service November 28, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve duplex scans of extracranial arteries. 
 
You asked the Plan to pre-approve duplex scans of extracranial arteries. The Plan denied your request. The 
Plan says this request 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 duplex scans of extracranial arteries. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation does not support the rationale for a repeat imaging 
study. Guidelines do not support a need for repeating the carotid duplex scan extracranial bilateral study 
(93880). Our reviewer also found that at this time cardiac doppler imaging 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 duplex scans of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve duplex scans of extracranial arteries.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 93970 rendered on 
December 27, 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 the medical records only support one unit of 93970. 
 
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 93970 is Duplex scan of extremity veins including 
responses to compression and other maneuvers; complete bilateral study. 
 
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 93970 represents a complete 
bilateral extremity venous doppler. The enrollee had one such exam on this date of service. There is no 
additional venous study documented. 
 
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 an additional unit of procedure code 93970 rendered on December 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnographies (codes 95810 and 95811). 
 
You asked the Plan to pre-approve polysomnographies. The Plan denied your request. The Plan says Medicare 
only covers Type I, II, III, and IV sleep tests and devices if you have clinical signs and symptoms of sleep 
apnea. 
 
The Plan follows Medicare rules. Medicare rules say that a polysomnography is not covered for the diagnosis 
of patients with chronic insomnia. 
 
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 polysomnographies. Our reviewer says 
that an attended polysomnography is not medically necessary. Our physician reviewer found you were seen on 
May 8, 2023, for insomnia. The notes from that clinical visit do not provide any other sleep history. Our 
reviewer found that there is no mention of suspicion for obstructive sleep apnea or sleep disorders other than 
insomnia. Our physician reviewer also found that insomnia is not an indication for polysomnography. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of polysomnographies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve polysomnographies (codes 95810 and 95811).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS). 
 
You asked the Plan to pre-approve TMS. You say that the enrollee has treatment-resistant major depressive 
disorder and has tried 8 antidepressants over a 20 year span. The Plan denied your request. The Plan says the 
enrollee has not tried therapy in over 20 years and most of the medications the enrollee tried were a long time 
ago. 
 
The Plan follows Medicare rules. Medicare rules state that TMS may be covered if certain 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 TMS. Our reviewer says that the 
enrollee does not meet criteria for TMS. Our physician reviewer found the enrollee does not have severe major 
depressive disorder according to the patient health questionnaire 9 (PHQ-9) and has tried only 2 medications 
during the current episode of depression. The use of TMS is not considered reasonable or medically necessary 
based on the enrollee's current condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcranial magnetic stimulation (TMS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 1, 2023. 
 
You asked the Plan to pay for the specialist visit. You say that you received a bill for $186.12. You also say 
that you thought you would only be responsible for a $35 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 $35 
copayment for Physician/Practitioner services.  
 
You have been asked to pay a $35 copayment for the specialist visit. This item/service falls within the Physician/Practitioner 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 pay for the office visit 
provided on February 1, 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's doctor requested acute care. You say 
that the enrollee does not have legs. You also say that the enrollee needs to learn how to get around after losing 
their legs. The Plan denied your request. The Plan says the requested care is not medically necessary. 
 
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 provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the requested IRF 
admission 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 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the request is not medically necessary. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. The Plan argues that 
ongoing SNF care is no longer necessary, citing in their review the enrollees function on 7/7/2023, 7/10/2023 
and 7/18/2023. No such records are identified for IRE review. As such, the Plan has failed to support its denial. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve a continuation 
of SNF care.  
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric mobility scooter (E1399). 
 
You asked the Plan to pre-approve an electric scooter. You say that an electric scooter is medically necessary 
for your mobility needs. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 electric scooter. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that you can use an assistive device to perform your MRADLs within your home. 
 
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 electric scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an electric mobility scooter (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2023, to February 25, 2023. 
 
  You asked the Plan to pay for procedure code S9328. You say that authorization was granted for codes S9328, 
99601, 99602, 62368 and 62369. You say that the participating provider referred the enrollee to avoid any 
complications and the claim should be reprocessed for payment. The Plan denied your request. The Plan says 
the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2023, to February 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on March 27, 2023. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this was a 
diagnostic eye examination with refraction determination. The eye refraction is not covered by the Plan.  
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on March 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 13, 
2023. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 70450 billed for date of service March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94015 billed for date of service July 20, 
2021. 
 
You asked the Plan to pay for procedure code 94015. You say that the records illustrate the need for services. 
The Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 3 for CPT code 94015. This indicator identifies 
standalone codes that describe the technical component for which there is an associated code that describes the 
professional component. Based on this information, we decided that Medicare rules for coverage of procedure 
code 94015 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
94015 billed for date of service July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01638 billed for date of service January 17, 
2023. 
 
You asked the Plan to pay for the billed services. You say that you provide the professional interpretation of 
radiological procedures. The Plan denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We find that CPT code 01638 was billed with 22, an outpatient hospital facility place of service code. The 
enrollees claim information shows that the enrollee was an inpatient at the time the services were provided.. 
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 code 01638 billed for date of 
service January 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on June 3, 2022, to 
June 5, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
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 N17.9. 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 use of diagnosis code N17.9 is not supported by the records provided. Our physician reviewer found 
that while creatinine was mildly elevated, there is no documentation that this reflects an acute renal failure, and 
thus does not support diagnosis code N17.9.  
 
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 the inpatient hospital services provided on June 3, 2022, to June 5, 2022, at the Diagnosis Related Group 
(DRG) originally billed.