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

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is necessary for you to continue 
strengthening, endurance work and medical management. The Plan denied your request. The Plan says you do 
not meet all the requirements for admission to an IRF.  
 
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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99222 and 99401 billed for date of service 
February 16, 2023.  
 
You asked the Plan to pay for procedure codes 99222 and 99401. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 99222 and 99401 is bundled into 
payment for code 99223. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 99222 and 99401 are column II codes to column I code 99223 with a modifier indicator of 0. The column II 
codes are therefore not payable. 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 codes 99222 and 99401 billed for date 
of service February 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided 
January 13, 2023, to January 19, 2023. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that you have outlined how this 
enrollee's medical necessity actually meets the guidelines that qualify for coverage. The Plan denied your 
request. The Plan says this service does not meet this requirement of the enrollee's Plan of benefits and is 
excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a water circulating heat pad with pump (E0217) provided January 13, 2023, to January 
19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80053, 80061, 82248, 82306, 82607, 
83036, 84443, 85025) provided on December 13, 2022. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says insufficient 
information was provided to review this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Specifically, the record shows that the Plan sent multiple requests for medical records to support the claim. 
This information was not received. Without this information we are unable to verify if the services at issue met 
criteria for coverage.  Therefore, we decided that the Plan does not have to pay for the laboratory services 
(80053, 80061, 82248, 82306, 82607, 83036, 84443, 85025) provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that the requested services are a necessity for your 
care. The Plan denied your request. The Plan says you have exhausted the routine-transportation benefit for the 
year. 
 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. 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 additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex at L4-L5. 
 
You asked the Plan to pre-approve a Vertiflex. You say that the enrollee has back pain and would like this 
procedure. The Plan denied your request. The Plan says this procedure is unproven and not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental, and more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex at L4-L5.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, 99214 and J1817 
billed for date of service February 8, 2023. 
 You asked the Plan to pay for procedure codes 96365, 96366, 96521, 99214 and J1817. You say that you have 
billed the services at issue correctly. The Plan denied your request. The Plan says the provided 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, we have confirmed that code 99214 is a column II code to column I codes 96365 and 96521; 
however, code 99214 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 96365, 96366, 96521, 99214 and J1817. 
Our reviewer says that procedure codes 96365, 96366, 96521, 99214 and J1817 do not meet criteria for 
payment. Our reviewer found that the provided records in this case do not support that code 99214 was distinct 
from CPT codes 96365 and 96521. Code 99214 represents an office or other outpatient visit for the evaluation 
and management of an established patient with 30-39 minutes of total time spent on the date of the encounter. 
The encounter note indicates 20 minutes were spent with the enrollee in this case. In addition, a visit "for 
Progressive infusion" is not covered by Medicare. 
 
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 96365, 96366, 96521, 99214 and J1817 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, 99214 and 
J1817 billed for date of service February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 billed for 
February 16, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 96365, 96366, and 96521 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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is refilling and maintenance 
of portable pump.  
We find that CPT codes 96365, 96366, and 96521 are not supported in the medical record. Specifically, the 
records show that outpatient intravenous insulin treatment (OIVIT) was performed and there is a more 
appropriate set of codes for these services. 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 96365, 96366, and 96521 billed for February 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 3, 
2021, to January 4, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
You also say that the services were rendered to the enrollee in good faith. The Plan denied your request. The 
Plan says the inpatient services were not medically necessary. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented with suspected acute coronary syndrome (ACS). Therefore, the 
reviewer found that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier emergency department (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 care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from January 3, 2021, to January 4, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97530 and 97110 billed for date of service 
April 17, 2023. 
 
You asked the Plan to pay for procedure codes 97530 and 97110. You say that these services were necessary 
and are supported as billed. The Plan denied your request. The Plan says these codes are not supported in the 
medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 97530 and 97110 is not supported in the medical record. Specifically, the records 
provided do not note the time spent performing these specific services. Both codes have time-based 
requirements, and therefore cannot be verified without this information. Based on this information, we decided 
that Medicare rules for coverage of procedure codes 97530 and 97110 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 97530 and 97110 billed for date of service April 
17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 21089 and 99205 billed for date of service 
January 19, 2023, to February 21, 2023. 
 
You asked the Plan to pay for procedure codes 21089 and 99205. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says these codes are not supported in the medical 
record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 21089 and 99205. Our reviewer says that 
the record does not support the codes in question. Our reviewer found the record states that the enrollee had an 
acute illness with systemic symptoms and the decision for elective surgery. This indicates moderate medical decision making, not high. There is a more specific code for the evaluation and management service provided. 
In addition, 21089 is an unlisted code which requires a detailed description of the procedure, which is not 
included in the medical record. Therefore, neither code is supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 21089 and 99205 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 21089 and 99205 billed for date of service January 19, 
2023, to February 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Neulasta. 
 
You asked the Plan to pre-approve Neulasta. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is enrolled in a clinical trial; therefore, the Plan is not responsible for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Neulasta as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve use of Neulasta.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 27093, J1100, and G3002 billed for date of 
service April 12, 2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the services. The 
Plan denied your request. The Plan says the billed codes 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. 
 
The CPT Code Manual definition of code 27093 is injection procedure for hip arthrography; without 
anesthesia. We find that CPT code 27093 is not supported in the records. There is a more accurate code that 
describes the hip injection provided.  
 The definition of code J1100 is injection, dexamethasone sodium phosphate, 1 mg. We find that code J1100 is 
not supported in the records. The claim billed 4 units of code J1100. The records show that 2 mg of 
Dexamethasone was provided.  
 
The definition of code G3002 is chronic pain management and treatment, monthly bundle including, diagnosis; 
assessment and monitoring; administration of a validated pain rating scale or tool. Required initial face-to-face 
visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes 
personally provided by physician or other qualified health care professional, per calendar month. We find that 
code G3002 is not supported in the records. The records do not support that this service was provided in 
addition to the office visit (code 99213) provided.  
 
We looked at the file and the rules. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 27093, J1100, and G3002 billed for date of service April 12, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on December 29, 2022, billed with 
procedure code 96366-59 (x2). 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that 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, the CPT Code Manual definition of 
code 96366-59 (x2) is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); 
each additional hour (List separately in addition to code for primary procedure). 
 
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 support the billed code. Our reviewer found that documentation with the flow sheets states 
the infusion was started at 1330 and discharged at 1540. As such, 2 units of 96366 is billed correctly. 
 
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 been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on December 29, 2022, billed with procedure code 96366-59 
(x2).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeomin. 
 
You asked the Plan to pre-approve Xeomin. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested use of this drug is not supported.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Xeomin. Our reviewer says that the 
requested use of Xeomin is not supported. Our physician reviewer found Xeomin is not Food and Drug 
Administration-approved for the enrollee's diagnosis of trigeminal neuralgia. This use is also not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xeomin have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Xeomin.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided from February 28, 2023, to 
March 16, 2023 
 
You asked the Plan to pay for acupuncture. You say that this was billed correctly and should be covered. The 
Plan denied your request. The Plan says this is not covered to treat your condition. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the records shows that the services at issue were not 
provided to treat CLBP. Therefore, we decided that the Plan does not have to pay for acupuncture services 
provided from February 28, 2023, to March 16, 2023