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

 
We decided that the Plan has to pay for procedure code 99214-25 provided on January 10, 2023. 
 
You asked the Plan to pay for procedure code 99214-25. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered 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 99214 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
We find that CPT code 99214 is supported in the medical record. Specifically, the records document that an 
office visit for the evaluation and management of the enrollee included a medically appropriate history and/or 
examination and moderate level of medical decision making on January 10, 2023, the same day as the surgical 
procedure (28470) provided by the same provider. Based on this information, we decided that Medicare rules 
for coverage of procedure code 99214-25 have been met. Therefore, we decided that the Plan has to pay for 
procedure code 99214-25 provided on January 10, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve upgraded electronics. You say that the enrollee is wheelchair dependent and 
has contributory weakness of upper extremities which makes it difficult for them to perform personal cares for 
self without a reclining seat back. The Plan denied your request. The Plan says the records do not show a 
medical need for the enrollee to control the power options through the joystick.  
 
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 upgraded electronics. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has adequate upper body strength to manage the standard power 
drive controls. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve upgraded electronics (E2311, E2313, E2377).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 6, 2023, to 
February 7, 2023.  
 
You asked the Plan to pay for acute inpatient hospital care. You say that you thought you were having a stroke 
and called 911 and was taken to the nearest hospital for observation. The Plan denied your request. The Plan 
says that there is no documentation provided to support the expectation that the member would have required a 
two midnight stay. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that your necessary hospital care (including earlier emergency department 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from February 6, 2023, to February 7, 2023.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hearing aids to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the hearing aids. You say that you have tried the network hearing aids 
previously and they did not work for you. You say you want a different vendor. The Plan denied your request. 
The Plan says the service is not a covered benefit. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the hearing aids. We found no exception that would require the Plan to pre-approve 
the hearing aids. Therefore, we decided that the Plan does not have to pre-approve the hearing aids to be 
provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an x-ray provided on February 10, 2023. 
 
You asked the Plan to waive the deductible for the x-ray. You say that your doctor wanted x-rays to verify if 
you have arthritis on your left knee. 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. Your 
contract with the Plan says that there is $150 deductible which applies to outpatient hospital services.  
 
The item or service you asked the Plan to pay for falls within the outpatient hospital services benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is $150 deductible, which 
applies to outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the 
time the x-ray was received on February 10, 2023. Therefore, we decided that the Plan does not have to waive 
the deductible for an x-ray provided on February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance UTI panel provided on April 6, 2023. 
 
You asked the Plan to pay for the Guidance UTI panel. You say that this testing should be covered. The Plan 
denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the Guidance UTI panel have not been met. Therefore, we decided that the Plan does not have to pay for the Guidance UTI panel provided on April 6, 
2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on December 
15, 2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that this should be paid as many 
other claims with the same procedure and diagnosis codes were paid in the past. The Plan denied your request. 
The Plan says the diagnosis codes reported are not appropriate to report together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill according to ICD-10-CM 
guidelines. The guidelines state that a diagnosis code may have an Excludes1 note which indicates codes it should not be reported with.  
 
We looked at the file and Medicare rules. This claim was reported with diagnosis code F31.30 and F32.2. The 
F32 code set has an Excludes1 note for all codes within the F31 code set, meaning they should not be reported 
together. Based on this information, we decided that Medicare rules for coverage of the outpatient mental 
health services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient 
mental health services provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency transportation. 
 
You asked the Plan to pay for the non-emergency transportation. You say that the enrollee needs the 
transportation for dialysis. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
 
 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 10 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 pay for the non-emergency transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 36010, 37252, 37253, 96360 and 96361 billed for date 
of service October 8, 2021.  
 
You asked the Plan to pay for codes 36010, 37252, 37253, 96360 and 96361. You say that the services billed 
were necessary and reported correctly.  The Plan denied your request. The Plan says the codes billed were not 
supported for reporting in this case. 
 
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 36010 is introduction of catheter, superior or inferior 
vena cava. 
 
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 codes 36010, 37252, 37253, 96360 and 96361. Our reviewer 
says that the criteria for coverage have not been met.  Our reviewer found code 36010 was not supported 
because the provider reported modifier 50 for a bilateral procedure. However, the documentation describes left 
only, and therefore the code billed as it was cannot be verified.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
37252, 37253, and 96361 are add-on codes and have not been billed with appropriate primary procedure codes.  
 
We have confirmed that code 96360 is a column II code to column I code 75820. This claim has not been billed 
with an appropriate modifier to bypass the edit. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 36010, 37252, 37253, 96360 and 96361 have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 36010, 37252, 37253, 96360 and 96361 billed for date of 
service October 8, 2021.
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 the enrollee would benefit from and can tolerate an 
intensive interdisciplinary treatment program under the supervision of a physician. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. The Plan denied your request. The Plan says the 
genicular nerve block 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 genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve blocks is the subject of ongoing trials and is considered experimental and investigational. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary.  
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 17, 2022, to 
October 18, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
removal of diagnosis code A41.9 is not correct. The Plan denied your request. The Plan says the conditions did 
not qualify for reporting. 
 
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, defined as sepsis, 
unspecified. 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 the billing of primary diagnosis code, A41.9, is not supported. 
Our physician reviewer found that the enrollee presented following a syncopal episode during a medical 
procedure. The enrollee reported a poor appetite and was confirmed to have dehydration and acute kidney 
injury. The enrollee was provided with intravenous fluids and treated for a possible urinary tract infection. The 
enrollee quickly improved and left against medical advice. There is no evidence that the enrollee had sepsis.  
As such, the billing of A41.9 as the principal diagnosis is not supported.  
 
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 October 17, 2022, to October 18, 2022, at the DRG originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 81225, 81226, 81240, 81241 and 81328 billed for date 
of service September 13, 2022. 
 
You asked the Plan to pay for codes 81225, 81226, 81240, 81241 and 81328. You say that you billed the 
services correctly.  The Plan denied your request. The Plan says the provided records do not support the codes 
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 81225 is CYP2C19 (cytochrome P450, family 2, 
subfamily C, polypeptide 19), gene analysis, common variants. The CPT Code Manual definition of code 
81226 is CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6), gene analysis, common variants. 
The CPT Code Manual definition of code 81240 is F2 (prothrombin, coagulation factor II) gene analysis, 20210G greater than (>) A variant. The CPT Code Manual definition of code 81241 is F5 (coagulation factor 
V) gene analysis, Leiden variant. The CPT Code Manual definition of code 81328 is SLCO1B1 (solute carrier 
organic anion transporter family, member 1B1), gene analysis, common variant(s). 
 
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 codes 81225, 81226, 81240, 81241 and 81328. Our reviewer 
says that the criteria for coverage have not been met.  Our reviewer found a combined Cardio (117 genes)/PGX 
(32 genes) panel was performed; code 81455 is used when a gene panel of 51 or more genes is tested. Provided 
records in this case indicate code 81455 is the more appropriate code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 81225, 81226, 81240, 81241 and 81328 have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 81225, 81226, 81240, 81241 and 81328 billed for date of 
service September 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the power scooter purchased on 
September 7, 2022. 
 
You asked the Plan to provide reimbursement for the power scooter. You say that you were told a power 
scooter would be covered. The Plan denied your request. The Plan says you appear to be ambulatory within 
your home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 provide reimbursement for the power scooter. Our 
reviewer says that the power scooter was not medically necessary. Our physician reviewer found that you can 
walk household distances and do not require a power operated vehicle to complete your MRADLs in our home. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to provide reimbursement for the power scooter purchased on September 7, 2022.