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

 
We decided that the Plan does not have to pay for the moderate sedation services provided on June 24, 2022, 
billed with codes 99152 and 99153. 
 You asked the Plan to pay for procedure codes 99152 and 99153. You say that  The Plan denied your request. 
The Plan says code 99152 is not supported in the record, and code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
The code definition of 99152 is moderate sedation services provided by the same physician or other qualified 
health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring 
the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We 
find that this code is not supported as the record does not include documentation of an independent qualified 
observer.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the moderate sedation services provided on June 24, 2022, billed with codes 99152 and 
99153.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a caudal steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says a caudal steroid 
injection 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 injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that there is no documentation of 
advance imaging or a physical exam. Therefore, the procedure 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a caudal steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rechargeable heated gloves provided on December 12, 2022. 
 
You asked the Plan to pay for rechargeable heated gloves. You say that the items in dispute were purchased so 
that you could continue your active recreation in the outdoors.  The Plan denied your request. The Plan says the 
items in dispute are not covered by Medicare and do not qualify for your supplemental Wellness Wallet 
benefit.  
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The Plan offers a Wellness Wallet benefit that exceeds Medicare coverage for certain items. 
For that reason, the Plans coverage rules also apply in this case.  
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. In addition, the 
Plans supplemental Wellness Wallet benefit for fitness is limited to fitness membership fees, personal trainer 
fees at a facility, fitness class fees, and non-recreational at home fitness equipment. The rechargeable heated 
gloves in dispute do not fall under these categories. Therefore, we decided that the Plan does not have to pay 
for rechargeable heated gloves provided on December 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 28, 2022, 
to March 24, 2022. 
 You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the NOA 
was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 28, 2022. The NOA was not received by the Plan until May 5, 
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 services 
provided from February 28, 2022, to March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder Detect test (0012M) provided August 30, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you appreciate prompt review of this 
information and authorization of coverage for CxBladder Detect test for this enrollee. The Plan denied your 
request. The Plan says the service does not meet medical necessity criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
CxBladder Detect test (0012M) provided August 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on February 8, 2023. 
 
You asked the Plan to pay for the physical therapy services. You say that these services were prior authorized 
and other claims have paid with these same diagnoses. The Plan denied your request. The Plan says you billed 
with an incorrect pair of diagnoses on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of R26.9 and R27.0. Code R27.0 is an Excludes1 code under 
code R26.9, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have 
to pay for physical therapy services provided on February 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder Monitor test (0013M) provided January 9, 2023. 
 
You asked the Plan to pay for genetic testing. You say that you would appreciate prompt review of this 
information and authorization of coverage for the CxBladder Monitor test for this enrollee. The Plan denied 
your request. The Plan says the CxBladder panel remains unproven at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
CxBladder Monitor test (0013M) provided January 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 8206, 82607, 82746, 84439 
and 84443 provided February 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you were not provided with the correct 
diagnosis codes from the referring provider. You tried to contact the enrollee for correct information but was 
not able to obtain the information timely. The Plan denied your request. The Plan says the claim was received 
after the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until February 23, 202. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded as 8206, 82607, 82746, 84439 and 
84443 provided February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transforaminal epidural steroid injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says the 
transforaminal epidural steroid injections are 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 injections. Our reviewer says that 
the enrollee does not meet the coverage criteria. Our physician reviewer found that an imaging of the spine 
before performing an epidural steroid injection is standard care. 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the transforaminal epidural steroid injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital admission. 
 
You asked the Plan to pre-approve an acute inpatient hospital admission. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the enrollee is undergoing a planned total shoulder 
arthroplasty. The enrollee is medically stable and has been provided medical clearance to undergo this elective 
procedure. The enrollee does not meet criteria for inpatient admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  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 acute inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for an inpatient hospital admission is 
met in this case. Our physician reviewer found the enrollee has a diagnosis of primary osteoarthritis of right 
shoulder. Per the reviewed documentation, the enrollee is undergoing a planned total shoulder arthroplasty. He 
is medically stable and has been provided medical clearance to undergo this elective procedure. The planned 
procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is 
currently approved as an ambulatory procedure. There is no documentation provided to support the expectation 
the enrollee will require a greater than 2 midnight stay. In conclusion, the health plan feels that the denial of the 
requested elective inpatient admission was appropriate given the guidance presented above. The review has 
determined that the record does not show that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an acute inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does not meet 
criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee was admitted to the acute hospital after a fall and left humerus fracture on June 24, 2023. 
His history is also significant for A-fib, pacemaker placement, and AKI on CKD. He was evaluated by 
orthopedic surgery, given conservative management, and is awaiting IRF placement. His PLOF is noted to 
have been generally independent at home with daily outside assistance from paid caregivers or family. The 
treating team specifically recommended IRF placement to optimize his return to mobility and ADL 
independence through adaptation given his arm injury, and manage his pain, kidney/heart function as well as 
tendency toward altered mental status. Per Medicare Benefit Policy Manual Ch 1, 110, and 42 CFR 412.622, 
the medical record overall significantly complies with the various documentation requirements for IRF 
admission (e.g., as best summarized by the IRF intake form and physician appeal of the denial). While the 
nature of his primary orthopedic injury might not ordinarily, on its own, require acute rehab, the combination 
of the enrollee's age, frailty, and overall comorbidities do require a high level of coordination and skill by his 
treating team to prevent another avoidable acute hospitalization. There is no indication that he will not be able 
to participate and benefit from physical therapy and occupational therapy at the levels required by Medicare. 
Therefore, the requested inpatient rehab facility admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the lumbosacral spine (72100) provided on 
February 10, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the x-ray exam of the lumbosacral spine (72100) provided on February 10, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93000 billed for date of service October 11, 
2022. 
 You asked the Plan to pay for procedure code 93000. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 93000 is bundled into 
payment for code G0402. 
 
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 93000 
is a column II code to column I code G0402. 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 93000 billed for date of service October 11, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve billed for date of 
service November 28, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records support the need. The Plan 
denied your request. The Plan says knee instability was not documented. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are relevant 
medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve billed for 
date of service November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87653 and 87798 for date of service 
October 14, 2022. 
 You asked the Plan to pay for procedure codes 87653 and 87798. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services were billed without a diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that services rendered must be billed with diagnosis 
codes. 
 
We looked at the file and Medicare rules. Review of the file shows that the claim was submitted without a 
diagnosis. Based on this information, we decided that Medicare rules for coverage of procedure codes 87653 
and 87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87653 and 87798 for date of service October 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the requested SNF admission is necessary due to the 
enrollee's physical decline. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
guidelines for services in a SNF.  
 
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 enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 16, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) and a 
bone graft (D6104) for tooth #30. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
procedures. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because implants and all related services are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical placement of implant body (D6010) and a bone graft (D6104) for tooth #30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that due to the risk factors and lack of 
mobility, you feel the Plan's denial was made in error. The Plan denied your request. The Plan says this device 
is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).