Persius/hicric huggingface dataset:
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. You say that the request should be 
reconsidered.  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 the 
radiofrequency ablation is considered an experimental and investigational procedure because of the wide 
variation of efficacy of the sacroiliac joint. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service March 23, 2023. 
 
You asked the Plan to pay for code 99223. You say that this code was billed correctly. The Plan denied your 
request. The Plan says you billed the incorrect Place of Service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99223 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99223 billed for date of service March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on March 16, 2023. 
 
You asked the Plan to pay for the telehealth services. You say that per the records, the provider is enrolled 
under the patient's benefit plan and the services are necessary for the patient. The Plan denied your request. The 
Plan says out-of-network virtual care is not covered under the members benefit plan. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) is 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover virtual care services out-
of-network. Based on this information, we decided that the Plans rules for coverage of the virtual care services 
have not been met. Therefore, we decided that the Plan does not have to pay for virtual care services provided 
on March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood glucose test strips provided by an out-of-network 
provider on February 22, 2022. 
 
You asked the Plan to pay for the blood glucose test strips. You say that the claim was originally filed on time. 
The Plan denied your request. The Plan says the claim was filed more than 1 calendar year from the date of 
service. 
 
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 blood glucose test strips was not filed until April 6, 2023. 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 blood glucose test strips provided by an out-of-network 
provider on February 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service December 
27, 2022 to January 17, 2023. 
 
You asked the Plan to pay for procedure code S9338. You say that this claim should be paid. 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 S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for date of service December 27, 2022 to January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D7953) for tooth #14 provided 
on March 7, 2023. 
 
You asked the Plan to pay for the dental service. You say that the oral surgeon said the procedure was 
medically necessary. The Plan denied your request. The Plan says your annual dental maximum benefit for the 
year has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $96 for dental services on January 11, 2023. On February 9, 2023, the Plan paid $101 for 
dental services. On February 21, 2023, the Plan paid $126 for dental services. On March 7, 2023, the Plan paid 
$677 for dental services. For the year of 2023 the Plan paid $1,000 ($96 paid + $101 paid + $126 paid + $677 
paid) for dental services; therefore, your annual dental maximum benefit for the year of 2023 was exhausted on 
the date of service of March 7, 2023. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft (D7953) for tooth #14 provided on March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 6, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 118 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional transportation trips 
for dialysis appointments. The Plan denied your request. The Plan says you have exceeded your benefit limit. 
This request is not covered by the plan. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve 118 
additional transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve 118 additional routine transportation trips (A0120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is the primary 
treatment for chronic low back pain where Modic changes exist. The appellant states that the enrollee's pain 
and radiologic findings indicate that the Intracept procedure is medically necessary. The Plan denied your 
request. The Plan says the Intracept procedure is not medically necessary. The Plan says medical studies have 
not proven that this service is helpful for the treatment of the enrollee's health problem. 
 
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 Intracept procedure. Our reviewer 
says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the magnetic resonance imaging (MRI) shows spinal stenosis and multiple degenerative 
changes including facet degenerative joint disease. This means that the cause of pain is unclear.  
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72141 and 99215 rendered on April 13, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain 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 the denied codes is: 
 
CPT 72141: 
 
Magnetic resonance (eg, proton) imaging (MRI), spinal canal and contents, cervical; without contrast material 
 CPT 99215: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using time 
for code selection, 40-54 minutes of total time is spent on the date of the encounter 
 
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 in this case, the documentation 
available for review does not support medical decision of high complexity. Additionally, the documentation 
does not support that an MRI was performed on the date in question. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 72141 and 99215 rendered on April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on August 10, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that per the records, the provider is enrolled 
under the patient's benefit plan and the services are necessary for the patient. The Plan denied your request. The 
Plan says out-of-network virtual care is not covered. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) is 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover virtual care services out-
of-network. Based on this information, we decided that the Plans rules for coverage of the virtual care services 
have not been met. Therefore, we decided that the Plan does not have to pay for virtual care services provided 
on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92960 billed for date of service February 21, 
2023. 
 You asked the Plan to pay for procedure code 92960. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 92960 is bundled into 
payment for code 00410-QK-QS. 
 
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 92960 
is a column II code to column I code 00410-QK-QS. 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 92960 billed for date of service 
February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for virtual care services provided on July 5, 2022. 
 
You asked the Plan to pay for the virtual care services. You say that per the records, the provider is enrolled 
under the patient's benefit plan and the services are necessary for the patient. The Plan denied your request. The 
Plan says no benefit coverage is available for virtual services performed by an out-of-network provider. The 
Plan authorization portal did not contain an authorization on file approving services rendered.  
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) is 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover virtual care services out-
of-network. Based on this information, we decided that the Plans rules for coverage of the virtual care services 
have not been met. Therefore, we decided that the Plan does not have to pay for virtual care services provided 
on July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for virtual care services provided on September 29, 2022. 
 
You asked the Plan to pay for virtual care services. You say that per the records, the provider is enrolled under 
the patient's benefit plan and the services are necessary for the patient. The Plan denied your request. The Plan 
says no benefit coverage is available for virtual services performed by an out-of-network provider. The Plan 
authorization portal did not contain an authorization on file approving services rendered.  
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) is 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover virtual care services  
out-of-network. Based on this information, we decided that Plans rules for coverage of virtual care services 
have not been met. Therefore, we decided that the Plan does not have to pay for virtual care services provided 
on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on April 20, 2023. 
 
You asked the Plan to pay for the telehealth services. You say that per the medical records, these service are 
covered under the patient's benefit plan and are necessary for the patient. The Plan denied your request. The 
Plan says telehealth services are not covered out-of-network. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) are 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that virtual care (also referred to as telehealth 
services, virtual check-ins or eVisits) are not covered out-of-network. Based on this information, we decided 
that the Plans rules for coverage of the telehealth services have not been met. Therefore, we decided that the 
Plan does not have to pay for telehealth services provided on April 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from November 11, 
2021, to December 2, 2021. 
 
You asked the Plan to pay for the services. You say that you submitted supporting documentation for 
reconsideration of this adjustment. The Plan denied your request. The Plan says there are items and services were determined to be inclusive to either room and board or the procedure charge and are not separately 
reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 charges denied with denial 
code G and H were reviewed, and denied correctly, as these charges would be included in the room and 
board charge. The records additionally do not support the items denied with K. The itemized bill documents 
ventilation assist and management was billed twice, which resulted in a duplicate payment. 
 
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 inpatient hospital services rendered from November 11, 2021, to December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99220 billed for date of service November 28, 2022. 
 
You asked the Plan to pay for code 99220. You say that this service was supported by the medical record. The 
Plan denied your request. The Plan says code 99220 is not supported by the medical record. The records don't 
support a comprehensive history of medical decision making of high complexity. 
 
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 99220 is Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patients and/or familys needs. Usually, the problem(s) requiring 
admission to observation status are of high severity. Typically, 70 minutes are spent at the bedside and on the patients hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 99220. Our reviewer says that code 99220 is not 
supported by the medical record. Our reviewer found the patient is a 69-year-old male who was treated in the 
emergency room on November 28, 2022. Documentation from that date describes the patient with an irregular 
heartbeat. The history was brief and focused. The examination was an expanded focus, and the vitals were 
stable. Atrial fibrillation was diagnosed. The plan was for troponin, electrocardiogram, other labs, and to start 
Cardizem and metoprolol and be placed in observation status then discharged home. The documentation does 
not support procedure code 99220 because in the history and physical, there was no evidence of a high level of 
complexity in the decision-making. The patient was stable and didn't require complex treatment or extensive 
workup.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99220 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99220 billed for date of service November 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the requested IGRT. You say that IGRT is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that IGRT is experimental/investigational for the 
enrollee's condition. 
 
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 the requested IGRT. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a male with metastatic prostate cancer with bone metastases involving the 
inferior right pubic ramus and the proximal right femur. He presents with the right hip pain. He has a previous 
history of prostatectomy in April 2013 and salvage radiotherapy in November 2013. 
 
The therapy plan and radiation treatment recommendation for 20 fractions are medically reasonable and 
necessary. Daily IGRT is medically reasonable and necessary in this case and must be approved due to several 
reasons. The dose/fraction regimen requires this in this situation. In addition, there is a previous history of 
salvage radiotherapy, and previous history of prostatectomy which likely results in daily changes/variations in 
bowel and bladder size and anatomic location. 
 
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 requested IGRT have been met. Therefore, we decided that the Plan has to 
pre-approve image-guided radiation therapy (IGRT).  
 
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.