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

 
We decided that the Plan does not have to pay for the services (99284) provided on April 20, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
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 the services. Our reviewer says that the use of code 99284 is 
not supported by the records provided. Our reviewer found that the member was stable, with normal vital signs and normal lab work. There was no sign of multiple system dysfunction nor a need for specialty consultation. 
The presentation was not one of high severity requiring urgent evaluation and no acute situation of a complex 
nature to support the level of care 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99284) provided on April 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast implant replacement and mastopexy (19325, 
19316). 
 
You asked the Plan to pre-approve the breast implant replacement and mastopexy. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the services are considered cosmetic in 
nature. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 breast implant replacement and 
mastopexy. Our reviewer says that the services are not medically necessary. Our reviewer found the records 
provided do not document that the requested procedure is for the prompt repair of accidental injury or to improve the functioning of a malformed body member.  The services appear to be cosmetic in nature. 
 
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 breast implant replacement and mastopexy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the breast implant replacement and mastopexy (19325, 
19316).
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 March 29, 
2023. 
 
You asked the Plan to pay for procedure code S9338. You say that previous claims have been 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 March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798 (x2) and 87634-59 billed for date of 
service February 16, 2023. 
 You asked the Plan to pay for procedure codes 87798 (x2) and 87634-59. You say that these services were 
necessary and were reported appropriately. The Plan denied your request. The Plan says these codes are not 
supported 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. 
 
In this case, we have confirmed that code 87634 is a column II code to column I code 87798; however, 87634 
was 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 87798 (x2) and 87634-59. Our reviewer 
says that these codes are not supported as billed. Our reviewer found two units of code 87798 are not supported 
in the medical records, as the documentation does not specify the organisms reported with code 87798. In 
addition, the provided records document that one specimen was tested for the date in question; therefore, code 
87634 is not supported as a distinct, separate or independent procedure from other services performed and 
paid.  
 
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 87798 (x2) and 87634-59 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87798 (x2) and 87634-59 billed for date of 
service February 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s) with imaging guidance (64635, 64636). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s) with 
imaging guidance. You say that this is medically necessary. The Plan denied your request. The Plan says 
medical necessity is not met as the enrollee received one diagnostic facet joint procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary not covered. Medicare rules also say that in order for thermal radiofrequency destruction of lumbar 
paravertebral facet joint nerves to be considered medically reasonable and necessary, patients must have had at 
least 2 MBBs, with each providing a consistent minimum of 80% sustained relief of primary pain. 
 
   
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 destruction by neurolytic agent, 
paravertebral facet joint nerve(s) with imaging guidance. Our reviewer says that the enrollee does not meet 
criteria for coverage. Our physician reviewer found the enrollee has had only one set of diagnostic MBBs 
which produced 100% of pain relief.  At this time, a second set is required before RFA.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, paravertebral facet joint nerve(s) with imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, paravertebral facet joint nerve(s) with imaging guidance (64635, 64636).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve the oncology (cutaneous melanoma) testing (0090U). 
 
You asked the Plan to pre-approve the genetic testing. You say that this test is a covered Medicare benefit 
under Molecular Diagnostic Tests (MoIDX): myPay Melanoma Assay L37879 and this enrollee meets the 
applicable LCD criteria. The Plan denied your request. The Plan says that the medical necessity criteria have 
not been met. 
 
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 genetic testing. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee with a biopsy showing lentiginous junctional melanocytic nevus with moderately 
atypical features present at the peripheral biopsy margin on the left posterior neck from biopsy on June 27, 
2023. Castle melanoma DX test was ordered which demonstrated the lesion to be likely melanoma in situ leading to further wide excision treatment. 
 
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 genetic testing have been met. Therefore, we decided that the Plan has to 
pre-approve the oncology (cutaneous melanoma) testing (0090U).  
 
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: 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 admission to a SNF is medically necessary. The 
Plan denied your request. The Plan says admission to a SNF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA). 
 
You asked the Plan to pre-approve PVA. You say that you have limited mobility due to spinal injury and are in 
need of other procedures but cannot do them until this one is done. The Plan denied your request. The Plan says 
that you do not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that Percutaneous Vertebral Augmentation may be 
covered under certain circumstances. 
 
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 PVA. Our reviewer says that you do not 
meet the indications for this procedure and do meet contraindications for this procedure. Our physician 
reviewer found that detailed documentation is not evident regarding worsening pain. There is no indication of a 
progression of the body height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a 
severe impact on daily activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of 
retropulsion (the tendency to lose your balance by leaning backward) and other plausible causes of your pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous vertebral augmentation (PVA).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable chest x-ray provided on April 13, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the portable chest x-ray. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says this service was not authorized. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the portable chest x-ray provided on April 13, 
2023, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need 
transportation to your medical appointment. The Plan denied your request. The Plan says your benefit only 
allows 36 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 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 routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 62.6 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 9, 2023, billed 
with procedure code 31625. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says documentation does not support the billed 
code. 
 
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 31625 is a column II code to column I code 31629; however, 31629 
was 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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that documentation does not support that 
CPT code 31625 was distinct from CPT code 31629. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on February 9, 2023, billed with procedure 
code 31625.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 22, 
2023.   
You asked the Plan to pay for procedure code 88341. You say that this claim was denied due to excessive units 
billed, but no units were paid on this claim.  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 88341 is 13 units. The MAI value for this code is 3. You billed 16 units of 
this code, exceeding the MUE.  
 
You did not provide evidence showing that the excess units were actually provided. Though it was noted that 
medical records were attached, these were not present in the file. There is evidence that attempts to obtain the 
necessary records were made by the Plan. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 88341 billed for date of service February 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on April 19, 2023. 
 
You asked the Plan to pay for the testing. 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there are no records to support a high suspicion or history of high-grade dysplasia, nor of esophageal cancer that might otherwise have increased the diagnostic value of the requested testing. The medical 
appropriateness and necessity of the requested testing is not apparent from provided records. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the testing provided on April 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an increase of home health aide services from 36 hours 
a week to 46 hours per week. 
 You asked the Plan to pre-approve home health services. You say that due to the enrollee's medical condition 
the enrollee needs additional hours because there is no one in the house who can help the enrollee. The Plan 
denied your request. The Plan says there is no evidence that additional home health aide services are needed.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented skilled home health needs. The requested services are not intermittent. As 
such, associated home health aide services are not shown to be medically necessary, reasonable, or coverable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an increase of home health aide services from 36 hours a week to 46 hours per 
week.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show you need an intensive team for 
your care. The Plan says that the services needed may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.