Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee clearly meets the Food 
and Drug Administration (FDA) indicates for use. The Plan denied your request. The Plan says the requested 
procedure 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 Intracept procedure. Our reviewer says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates more than one potential source for the 
enrollee's back pain. Therefore, the reviewer found that the requested Intracept procedure is not medically 
reasonable or 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the drug injection provided on January 24, 
2023, and the MRI provided on January 24, 2023. 
 
You asked the Plan to waive the cost share for the MRI and the drug injection. You say that you hope the Plan 
can cover the full cost of this procedure. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that your deductible is 
$600. Your contract with the Plan also says you must pay 10% coinsurance for in-network Medicare Part B 
prescription drugs, and a $200 copayment for in-network advanced imaging services at an outpatient hospital.  
 
You have been asked to pay $16.20 ($162.01 x 10% = $16.20) for the drug injection. This item/service falls 
within the Medicare Part B prescription drugs benefit category. You have also been asked to pay $800 for the 
MRI ($600 deductible + $200 copayment = $800). This item/service falls within the advanced imaging services 
benefit category. The amount you owe is $816.20 ($16.20 + $800 = $816.20). This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the cost share for the drug injection and MRI of the pelvis provided on January 24, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service October 2, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, this service was billed with 
diagnosis codes R44.0 (auditory hallucinations) and F20.9 (schizophrenia, unspecified). These diagnosis codes 
should not be reported together. The claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 for date of service October 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6222 billed for date of service February 3, 
2023. 
 
You asked the Plan to pay for procedure code A6222. The Plan denied your request. The Plan says procedure 
code A6222 is considered bundled and not separately payable.  
 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 A6222 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A6222 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
A6222 billed for date of service February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy (MNT) (97803) provided on 
November 10, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the service was medically 
necessary. The Plan denied your request. The Plan says medical nutrition therapy (MNT) is covered by 
Medicare only for diabetes and renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy (MNT) (97803) provided on November 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 18, 2022, to 
May 19, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is 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 inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, described as Sepsis, 
unspecified organism. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that documentation does not support the billed code. 
Our physician reviewer found the enrollee is a 57-year-old female with cerebral palsy who was hospitalized for 
acute pyelonephritis and ureteral stone, treated with antibiotics and stenting. Documentation describes enrollee 
as alert and oriented, with table vitals, normal creatinine, negative blood cultures, normal liver function test, 
and normal platelets which describes no objective evidence of a dysregulated response to infection causing 
organ damage to meet the Sepsis 3 criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 18, 2022, to May 19, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
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 home ventilator. Our reviewer says 
that the member does not need this item. Our physician reviewer found the provided records document that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with 
auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. Provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service October 17, 2022, to 
October 19, 2022. 
 
You asked the Plan to pay for code 99233. You say that the coding of 99233 is supported by the medical 
record. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99233 for dates of service October 17, 2022, to October 19, 2022. The medical records don't support a detailed 
interval 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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval 
history; A detailed examination; Medical decision making of high complexity. 
 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 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found the patient is a 66-year-old female who was treated in the 
hospital during the dates, October 17, 2022, to October 19, 2022, for acute gallstone pancreatitis who was 
awaiting outpatient cholecystectomy. The documentation for these dates described the patient with unchanged 
abdominal pain, without fever/chills with computed tomography (CT) scan showing possible pseudocyst and 
receiving pain medication and stable vitals and labs. There was insufficient support made for interval histories 
or medical decision-making of high complexity for these dates.  
 
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 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for dates of service October 17, 2022, to October 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for continued care.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372 for date of service November 14, 
2022. 
 
You asked the Plan to pay for procedure code 96372. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this service was billed with an inappropriate place of service. 
 
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 96372 is therapeutic, prophylactic, or diagnostic injection 
(specify substance or drug); subcutaneous or intramuscular. 
 
We find that CPT code 96372 is not supported in the medical record. Specifically, this service was billed with a 
place of service 23 (Emergency Room  Hospital). Code 96372 has a professional component/technical component indicator of 5. This means this code is incident to codes. This indicator identified codes that 
describe services covered incident to a physician's service when they are provided by auxiliary personnel 
employed by the physician and working under their direct supervision. Payment may not be made by carriers 
for these services when they are provided to hospital inpatients or patients in a hospital outpatient department. 
Modifier 26 and TC cannot be used with these codes. A portion of a hospital where emergency diagnosis and 
treatment of illness or injury is provided. Since the enrollee was in an outpatient hospital department the code is 
not payable. Based on this information, we decided that Medicare rules for coverage of procedure code 96372 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 96372 for date 
of service November 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport and ground transportation provided on December 1,  2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
transportation. You say that the submitted medical records support the ambulance transport was medically 
necessary.  The Plan denied your request. The Plan says this claim does not meet these requirements for the 
ambulance transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport and ground transportation. Our reviewer says that the ambulance services were not 
medically necessary. Our physician reviewer found the transportation via ambulance from the hospital to the enrollee's residence 
upon discharge was not medically necessary. The enrollee did not require the expertise of trained personnel or 
the equipment available only on an ambulance in order to effectuate a safe transport.  Transportation could 
have been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the 
enrollee's condition. 
 
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 ambulance service, basic life support, non-emergency transport and ground 
transportation have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
service, basic life support, non-emergency transport and ground transportation provided on December 1,  2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on April 22, 
2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the code billed is not supported by the records. 
 
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 99285 is an Emergency Department Visit  for the 
Evaluation and Management of a patient, requiring 3 key components: a comprehensive history, a 
comprehensive examination and medical decision making of high complexity. 
 
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 emergency room services. Our reviewer says that the 
records provided do not support the billed service. Our reviewer found the provided medical records do not 
support medical decision making of high complexity. 
 
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 emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services (99285) provided on April 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
December 30, 2022, to January 6, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you are on a fixed 
income, and this was an unexpected hospital event. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that for inpatient hospital 
care you must pay $275 per day for days 1 to 5 and $0 copayment after day 5.  
 
 You have been asked to pay a $1,375 copayment for the inpatient hospital care ($275/day x 5 days = $1,375). 
This item/service falls within the inpatient hospital care benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the inpatient hospital care provided from December 30, 2022, to January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Platelet Rich Plasma injection provided on  
November 11, 2022. 
 
 You asked the Plan to pay for the Platelet Rich Plasma injection . You say that the Platelet Rich Plasma 
injection was medically necessary. The Plan denied your request. The Plan says the requested Platelet Rich 
Plasma injection does not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. 
 
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 Platelet Rich Plasma injection. Our 
reviewer says that the Platelet Rich Plasma injection is not medically necessary. Our physician reviewer found 
a detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive 
conservative care measures is not evident. Moreover, as per the Medicare LCD, there is limited published, 
large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment 
for the noted pathology. No compelling rationale is presented, or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested platelet-rich plasma (PRP) 
injection for the right knee does not meet the Medicare LCD coverage criteria.  
 
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 Platelet Rich Plasma injection have not been met. Therefore, we decided 
that the Plan does not have to pay for a Platelet Rich Plasma injection provided on November 11, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for  the emergency room (ER) services provided on June 12, 2022. 
 
You asked the Plan to pay for  the ER services. You say that the services should be covered. The Plan denied 
your request. The Plan says that the provider is not enrolled in Medicare. 
 
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 physician does show up as a Medicare provider in the Medicare provider 
search. The Plan has not submitted any documentation showing otherwise. Therefore, we decided that the Plan 
has to pay for  the emergency room (ER) services provided on June 12, 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.