Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from August 14, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from August 14, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from August 
14, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of August 14, 2023, forward. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond August 14, 2023, as she 
was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services for 
the dates in question were reasonably expected or medically necessary to improve the enrollees condition or 
for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from August 14, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from August 14, 
2023, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 63057, 20939, 20937, and 63056 billed for 
March 16, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 63057, 20939, 20937, and 63056 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 63057 is transpedicular approach with decompression of 
spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional 
segment, thoracic or lumbar (List separately in addition to code for primary procedure). The definition of code 
20939 is bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision 
(List separately in addition to code for primary procedure). The definition of code 20937 is autograft for spine 
surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List 
separately in addition to code for primary procedure). The definition of code 63056 is transpedicular approach 
with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single 
segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated 
intervertebral disc). 
 
We find that CPT code 63057, 20939, 20937, and 63056 is not supported in the medical record. Specifically, 
the operative report does not include documentation of a transpedicular approach with decompression of the 
spinal cord, equina, and/or nerve roots for each additional thoracic or lumbar segment to support code 63057. 
There is no documentation of a bone marrow aspiration for bone grafting for spine surgery only to support code 
20939. There is no documentation of a morselized autograft for spine surgery only to support code 20937. 
There is no documentation of a transpedicular approach with decompression of the spinal cord, equina, and/or 
nerve roots for a single lumbar segment to support code 63056. 
 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 63057, 20939, 20937, and 63056 
billed for March 16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on January 29, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285.  The Plan denied your request. The Plan says the medical records do not support the billing of 
code 99285.  
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 99285. Our reviewer says that the medical records do not support the billing of code 99285.  Our reviewer found based on the documentation provided, 
the enrollee presented with dizziness. The overall history is not comprehensive. The physical examination is 
not comprehensive. The medical decision making is not of high complexity. The enrollees condition did not 
present an immediate threat to life or function. As such, the billing of CPT 99285 is not supported. 
 
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 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on January 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve block provided on January 9, 2023. 
 
You asked the Plan to pay for the genicular nerve block. The Plan denied your request. The Plan says the 
genicular nerve block 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 pay for the genicular nerve block. Our reviewer says 
that the genicular nerve block is not medically necessary. Our physician reviewer found that genicular nerve 
blocks is the subject of ongoing clinical trials to examine its role in the treatment of knee osteoarthritis. The 
enrollee is not enrolled in a clinical trial, and the request is considered experimental at this time. Therefore, the 
procedure was not medically reasonable and 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pay for the genicular nerve block provided on January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (G0402, G0404, G0463) provided on 
February 23, 2023. 
 
You asked the Plan to pay for outpatient services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes G0402, G0404, & G0463 are not supported in the medical record. Specifically, you 
billed two E & M procedure codes on the same date of service without condition code G0. Based on this 
information, we decided that Medicare rules for coverage of outpatient services have not been met. Therefore, 
we decided that the Plan does not have to pay for outpatient services (G0402, G0404, G0463) provided on 
February 23, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on February 23, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed service. 
 
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 99285 is an Emergency Department visit for the 
evaluation and management of a patient, with medical decision making of high complexity. 
 
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 99285. Our reviewer says that the records do 
not support the billed services. Our reviewer found there was no 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 procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that when one power seating 
function/actuator/motor is provided on a power wheelchair, one unit of E2311 is allowed. The Plan denied your 
request. The Plan says the electrical connection between the wheelchair controller and two motors (E2311) 
cannot be covered. The Plan also says that although two power features are requested for this wheelchair (tilt 
and elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
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 electronic connection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has 3 out of 5 strength in their elbow through wrists and is able to use a 
standard joystick per the physical therapy evaluation.  The enrollee has used a power wheelchair for 8 years. 
Our reviewer also found that the enrollee has adequate upper body strength to manage standard 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 an electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. The Plan denied your request. The Plan says 
the radiofrequency ablation 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 radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that 
the imaging is more than five years old. The LCD requires two separate sets of diagnostic MBBs each of which 
has to be documented to produce 80% or more pain relief. The enrollee only has one documented MBB, 
therefore the request is not medically reasonable and 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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service May 25, 
2022, to June 23, 2022. You asked the Plan to pay for the billed services. You say that appeals were submitted with supporting 
documentation. The Plan denied your request. The Plan says the NOA was not received timely. 
 
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 April 25, 2022. The NOA was not received by the Plan until October 25, 
2022. 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 the home health care billed for 
dates of service May 25, 2022, to June 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64629, 64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
spinal stenosis or facet degenerative joint disease (DJD). The cause of the pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64629, 64628).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visual field test provided on April 4, 
2023, and the medical eye exam provided on April 11, 2023. 
 
You asked the Plan to waive the copayment for the visual field test, and the eye exam. You say that you do not 
understand the cost sharing. 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 $60 
copayment for diagnostic procedures/tests, and a $45 copayment per Medicare-covered eye exam. 
 
You have been asked to pay a $60 copayment for the visual field test. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to 
pay a $45 copayment for the eye exam. This item/service falls within the vision care 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 the visual field test provided on April 4, 2023, and the 
medical eye exam provided on April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and 2 or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been 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 an electronic connection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has adequate upper body strength to manage standard 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 an electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and 2 or more power 
seating system motors (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653 and 87641 billed for 
date of service April 27, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87653 and 87641. You say that these services are 
supported in the medical record. The Plan denied your request. The Plan says these services are not supported 
for separate billing. 
 
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 codes 87150, 87481, 87653 and 87641 are column II codes to column I 
codes 87500 and/or 87801; however, 87150, 87481, 87653 and 87641 were each 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 codes 87150, 87481, 87653 and 87641. Our 
reviewer says that these services are not supported for separate reporting/billing. Our reviewer found the 
laboratory report does not include documentation to support these codes with modifier XU. These services 
cannot be verified as they were billed. 
 
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 87150, 87481, 87653 and 87641 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653 and 87641 billed for 
date of service April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on February 28, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on February 28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax applied to the home health care services 
provided from February 1, 2023, to February 26, 2023. 
 
You asked the Plan to pay for the sales tax. You say that the claims were not processed correctly and should be 
favorable. The Plan denied your request. The Plan says the denial for the sales tax is correct because Medicare 
does not pay sales tax. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not make separate payment for 
sales tax. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare does not make 
separate payment for the requested sales tax reimbursement. Therefore, we decided that the Plan does not have 
to pay for the sales tax applied to the home health care services provided from February 1, 2023, to February 
26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. 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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental therapy. It is the subject of ongoing clinical 
trials. 
 
   
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).