Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 95999. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 95861 and 95868.  
 
You asked the Plan to pay for testing services provided on May 10, 2022, billed with codes 95861-26, 95861-
26-XU, 95868-26, 95868-26-XU, and 95999. You say that the claim was billed correctly and should be paid. 
The Plan says that the units billed exceeds the Medicare allowed amount. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 95999.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 95999.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 95861 
and 95868. 
 
The Plan follows Medicare rules. Medicare rules say that submitted claims in which the unit of service exceeds 
the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess units.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 95861 and 95868 have not been met. In this case, the 
MUE for CPT codes 95861 and 95868 is 1 The MAI value for this code is 3. You billed 2 units of these codes, 
exceeding the MUE. You did not provide all the required evidence showing that the excess units were actually 
provided, were correctly coded, and were medically necessary. Therefore, we decided that the Plan does not 
have to pay for the services described by procedure code(s) 95861 and 95868. 
 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 procedure code 99458 billed for date of service February 28, 
2023.  
 
You asked the Plan to pay for procedure code 99458. You say that these units were medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99458 is 3. The MAI value for this code is 3. You billed 7 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. You have provided no argument for or 
explanation why these excess units were billed. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99458 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99458 billed for date of service February 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0657). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the requirements for approval. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee does not have lymphedema extending onto the chest, trunk and/or abdomen that extends 
past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema and has 
not failed to improve with a four-week trial. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0657).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound dressings provided on January 19, 2023.  
 
You asked the Plan to pay for the wound dressings. You say that this is separately payable as the enrollee is in 
an approved SNF stay.  The Plan denied your request. The Plan says this must be reimbursed by the SNF as it 
is included in the payment under Part A.  
 
The Plan must follow Medicare rules. Medicare rules say that SNFs must provide most items and services 
provided to Part A inpatients. Suppliers should look to the SNF for payment.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wound dressings have not been met. Therefore, we decided that the Plan does not have to pay 
for the wound dressings provided on January 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided on October 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for OON x-ray services. You say that this should not require authorization. The Plan 
denied your request. The Plan says OON services require authorization. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that most services 
obtained from out-of-network providers require prior authorization. 
 
We looked at the file and Medicare rules. The services at issue were not authorized. Based on this information, we decided that Medicare rules for coverage of OON x-ray services have not been met. Therefore, we decided 
that the Plan does not have to pay for x-ray services provided on October 31, 2022, by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 22830 and 63627 rendered on September 19, 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 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 22830: 
 
Exploration of spinal fusion 
 
CPT 63627: 
 
Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar 
 
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 procedure details site 
posterolateral fusion mass was explored. There was heterotopic bone and lipomatous appearing tissue, which 
extended through the facia and adjacent to the fusion mass. This was removed in a piecemeal fashion. There is 
on corroboration of an arthrodesis having been performed. Therefore, the records do support CPT 22830 in this 
case. In terms of CPT 63627, the procedure details site a prior laminectomy defect was seen at L5-S1. A 
revision was performed, right-sided hemilaminectomy, laminotomy, and medial facetectomy were performed 
in standard fashion to decompress the right-sided L5 and S1 nerve roots. Therefore, the records do support this 
code. 
 
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 
procedure codes 22830 and 63627 rendered on September 19, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mobile Cardiac Outpatient Telemetry (MCOT). 
 
You asked the Plan to pre-approve Mobile Cardiac Outpatient Telemetry (MCOT). You say that the requested 
MCOT is medically necessary. The Plan denied your request. The Plan says the requested MCOT 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 Mobile Cardiac Outpatient Telemetry 
(MCOT). Our reviewer says that the requested MCOT is not medically necessary. Our physician reviewer 
found the enrollee has a 6-12 month history of dyspnea and increased fatigue. There is no supportive evidence 
that the ordering practitioner documented any standard, non-MCOT, ambulatory electrocardiogram (ECG) 
monitoring. In summary, there is insufficient documentation to support the medical necessity for an MCOT monitor in this enrollee's 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 Mobile Cardiac Outpatient Telemetry (MCOT) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Mobile Cardiac Outpatient Telemetry (MCOT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator (NIV). 
 
You asked the Plan to pre-approve the NIV. You say that the NIV is medically necessary.  The Plan denied 
your request. The Plan says the enrollee does not require this device.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 NIV. Our reviewer says that the 
requested NIV is not medically reasonable and necessary.  Our physician reviewer found the enrollee was hospitalized in March 2023 with an exacerbation of heart failure. Arterial blood gas (ABG) was consistent with 
acute on chronic hypercarbic respiratory failure. Notes indicate the enrollee has a Trilogy device at home. A 
compliance download for the device covering March 28 through May 3, 2023, showed the enrollee using the 
device for at least 4 hours per day on 0% of days. There are no pulmonary function tests to confirm airway 
obstruction and assess severity. There is no ABG done while stable to confirm chronic carbon dioxide 
retention. If that is present, the enrollee may benefit from bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) during sleep. Medicare does not cover a home ventilator 
when used at settings that can be provided with BiPAP.  
 
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 NIV have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a non-invasive ventilator (NIV).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for osteotomy, with or without lengthening, shortening or angular 
correction, metatarsal; other than first metatarsal, each rendered on January 12, 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 that the billed Current Procedural Terminology (CPT) code 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. In this case, the CPT Code Manual definition of 
code 28308 is "Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other 
than first metatarsal, each." 
 
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 pprocedure details cite 
subperiosteal elevation performed and an MIS technique was performed, and a 60-degree angle osteotomized 
in the metatarsal neck and allowing the metatarsal capital fragment to translate medially reducing the 
deformity. This supports that an osteotomy was performed of the left 5th metatarsal. Therefore, the records do 
support that CPT 28308 was rendered in this case. 
 
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 
osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first 
metatarsal, each rendered on January 12, 2023.  
 
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 procedure codes 36140, 36246, 36247, 37233, 37253, 75630, 
75710 and 76998 billed for July 20, 2022. 
 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 36140, 36246, 36247, 37233, 37253, 75630, 75710 and 76998 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 37233 is revascularization, endovascular, open or 
percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty 
within the same vessel, when performed (List separately in addition to code for primary procedure). The 
definition of code 37253 is intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or 
therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary 
vessel (List separately in addition to code for primary procedure). The definition of code 36246 is selective 
catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, 
within a vascular family. 
  
We find that CPT codes 37233 and 37253 are not supported in the medical record. Specifically, there is no 
documentation of an open or percutaneous endovascular revascularization of a unilateral tibial/peroneal artery 
to support code 37233. There is no documentation of intravascular ultrasound of a noncoronary vessel to 
support code 37253. There is no documentation of selective catheter placement into the arterial system for the 
initial second order abdominal, pelvic, or lower extremity artery branch to support code 36246.  
 
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 
76998-26-59 is a column II code to column I code 37229. This claim has not been billed with an appropriate 
modifier to bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 
Based on the claim submitted, Medicare billing criteria have not been met. 
 
We have confirmed that codes 36247-59, 36140-59, and 75710-26-59 are column II codes to column I code 
37227. This claim has not been billed with an appropriate modifier to bypass the edit. The -59 modifier is not 
supported as a separate and distinct procedural service. Based on the claim submitted, Medicare billing criteria 
have not been met. 
 
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 36140, 36246, 36247, 37233, 
37253, 75630, 75710 and 76998 billed for July 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lantus Solostar. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lantus Solostar.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve critical care services provided on January 27, 2023. 
 
You asked the Plan to pre-approve the critical care services. You say that you billed with valid diagnoses. The 
Plan denied your request. The Plan says you billed an inappropriate 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 R29.810 and G51.0. Code G51.0 is an Excludes1 code 
under code R29.810, 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 critical care services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve critical care services provided on January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve additional accessories for a power wheelchair (E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the enrollee's upper limb strength and function are adequate for the enrollee to 
be able to control the power options using their own switches which are included in the allowance of these 
power options. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial in this case. Our reviewer found that 
the plan has asserted that the enrollee has adequate upper body strength. However, the plan has not supplied 
any records to verify this. The plan must supply records in support of its denial. Therefore, we decided that the 
Plan has to pre-approve additional accessories for a power wheelchair (E2313, E2377).  
 
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.