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

 
We decided that the Plan does not have to pay for the outpatient surgery services (intravitreal injections 
(Avastin) provided May 24, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that you disagree with this denial as evidenced 
by the enrollee's medical history summarized below as well as the attached supporting medical records for 
additional review. The Plan denied your request. The Plan says since a precertification was not obtained, this 
service is not covered. Charges for or in connection with services or supplies that are, as determined by the 
Plan, considered to be experimental or investigational are 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 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 outpatient services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the procedure performed (intravitreal Avastin injection) is an in-office minor 
procedure and is not considered an outpatient surgical service. The standard of care for this treatment is to 
administer the intravitreal injection in the clinic setting (American Academy of Ophthalmology, Preferred 
Practice Patterns - Diabetic Retinopathy, 2019, https://www.aao.org/education/preferred-practice-
pattern/diabetic-retinopathy-ppp). There is no documentation that the procedure could not have been performed 
in the office (usual standard of care) with an in-network provider. Therefore, the criteria are not met for 
medical necessity. 
 
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 outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the outpatient surgery services (intravitreal injections (Avastin) provided May 24, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit services coded as 99285, 
36415, 80053, 83690, 83735, 85025, 85027, 85610, 87641, U0003, U0005, 71045, and G0378 provided May 
11, 2021, to May 12, 2021. 
 
You asked the Plan to pay for the emergency visit. You say that you have never been paid for this service. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were reimbursed by the Plan on May 28, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the emergency visit have not been met. 
Therefore, we decided that the Plan does not have to pay for the emergency department visit services coded as 
99285, 36415, 80053, 83690, 83735, 85025, 85027, 85610, 87641, U0003, U0005, 71045, and G0378 provided 
May 11, 2021, to May 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve an SI joint injection. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections (SIJI) will be considered 
medically reasonable and necessary when certain requirements are met.  
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 an SI joint injection. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation on 
physical examination of tenderness to the SI joint and no mention of SI provocative testing being completed 
with positive findings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99222) rendered on May 
17, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 99222 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
does not support the CPT code 99222. The documentation available for review does not support that the 
encounter required medical decision making of moderate 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99222) rendered on May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism, electric, any type (E0627) provided 
November 17, 2022. 
 
You asked the Plan to pay for the seat lift mechanism. You say that you recently had surgery and find this chair 
is very helpful getting up and down in a sitting position. This chair is a large asset and additional boost to your 
health. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
We looked at the file and Medicare rules. The provided Certificate of Medical Necessity specifically indicates that the enrollee does not have severe arthritis of the hip or knee or a severe neuromuscular disease, is capable 
of standing up from a regular armchair in their home and once standing has the ability to ambulate. Based on 
this information, we decided that Medicare rules for coverage of the seat lift mechanism have not been met. 
Therefore, we decided that the Plan does not have to pay for the seat lift mechanism, electric, any type (E0627) 
provided November 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services (97110GP and 97140GP) 
provided on September 29, 2021. 
 
You asked the Plan to pay for the therapy services. You say that you were unaware the services received were 
beyond the services approved. The Plan denied your request. The Plan says the PT services rendered were not 
medically necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have previously been treated with outpatient therapies. There is 
no documentation of a recent injury or decline in function. The documentation does not support that medically 
necessary therapy services were received on the date in question. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pay for the physical therapy (PT) services (97110GP and 97140GP) provided on September 
29, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the foam dressing (A6212) provided on December 14, 2022. 
 
You asked the Plan to pay for the foam dressing. You say that the enrollee was referred by a network provider. 
The Plan denied your request. The Plan says that the requested service was provided out-of-network (OON). 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the foam dressing by a contract provider. The file does not show that the plan 
provided notice that the foam dressing would not be covered. Under Medicare rules, this means the foam 
dressing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the foam 
dressing (A6212) provided on December 14, 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 15, 2021, 
through September 17, 2021, and billed with diagnosis code A41.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.9 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of A41.9. 
 
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 primary diagnosis code A41.9-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 the documentation does not support the primary diagnosis of 
A41.9, Sepsis. Our physician reviewer found the member was evaluated and noted to have an increased white 
blood count (WBC) and increased lactic acid. The member was treated with intravenous Ceftriaxone, sodium 
bicarbonate (NaHCO3), and intravenous ceftriaxone antibiotics. The members condition was stabilized and 
improved with medical treatment. There was no laboratory or clinical evidence of sepsis. The review has 
determined that the documentation did not support the primary diagnosis code A41.9-Sepsis, unspecified 
organism. 
 
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 September 15, 2021, through September 17, 2021, and billed with 
diagnosis code A41.9.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service July 13, 2022. 
 
You asked the Plan to pay for code 99285. You say that this service was reasonable and necessary and the 
records support the code billed. The Plan denied your request. The Plan says code 99285 is not supported by 
the medical records. The records do not support 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the patient is a 66-year-old female who was treated in the 
emergency room. The history was detailed and described the patient with a pancreatic cyst, presenting with 
abdominal pain, nausea, vomiting, and diarrhea with bloating. The examination was detailed and revealed mild 
diffuse abdominal pain but no guarding and otherwise unremarkable. The workup revealed no leukocytosis, 
normal lipase, and otherwise unremarkable. Computed tomography showed a cyst on the patient's pancreas. 
She was treated with fluids, pain medication, and was antiemetic without vomiting and was discharged to 
follow-up as outpatient. The patient appeared stable. There was insufficient support made in the provided 
documentation for 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 code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service November 
24, 2022. 
 You asked the Plan to pay for procedure code 99291. You say that you disagree with the Plan's denial. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service November 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99283) and drainage of 
tailbone cyst (10080) provided March 30, 2021. 
 
You asked the Plan to pay for the emergency visit. You say that please review the attached, showing proof of 
your due diligence to meet these filing requirements and override the denial. The Plan denied your request. The 
Plan says the claim was submitted past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency visit was not filed until December 22, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the emergency department visit (99283) and drainage of tailbone 
cyst (10080) provided March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve podiatry services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON podiatry services. You say that care with this provider has been 
authorized in the past. The Plan denied your request. The Plan says you have not been receiving any specialize 
care from this OON provider, and you can receive routine podiatry services from an in-network provider. 
 
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
podiatry services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging and laboratory services billed with codes 71260, 
74160, 74018, and 85260 for November 25, 2022, to November 26, 2022. 
 
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 the services are not allowed for the submitted type of bill. 
 
The Plan must follow Medicare rules. The rules say that revenue code 0270 is considered a packaged service 
for Part B inpatient services.  
 
We looked at the file and Medicare rules. The file shows that the services at issue were billed with revenue 
code 0270. Payment for these services is packaged into the inpatient hospital payment. Therefore, we decided 
that the Plan does not have to pay for the imaging and laboratory services billed with codes 71260, 74160, 
74018, and 85260 for November 25, 2022, to November 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that the items are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.   
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided January 5, 2023. 
 
You asked the Plan to pay for the surgical pathology services. You say that you are asking for reconsideration 
of the out of network deductible that was applied to this claim. 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 $250 combined deductible which applies to Laboratory services.  
 
The item or service you asked the Plan to pay for falls within the Laboratory services benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is $250 combined deductible 
which applies to Laboratory services. This cost sharing is a contractual obligation that had not been met at the 
time the surgical pathology services was received on January 5, 2023. Therefore, we decided that the Plan does 
not have to pay for the surgical pathology services provided January 5, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the WATS cytopathology and histopathology diagnostic testing 
provided on August 24, 2022. 
 
You asked the Plan to pay for the WATS cytopathology and histopathology diagnostic testing. You say that 
this testing was medically necessary. The Plan denied your request. The Plan says that this service is not 
covered for screening purposes. 
 
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. In this case there were no medical records included in the case file. There is no 
documentation showing that the Plan attempted to obtain this information. Without this information we are 
unable to review whether this test was medically necessary or was ordered solely for screening purposes. 
Therefore, we decided that the Plan has to pay for the WATS cytopathology and histopathology diagnostic 
testing provided on August 24, 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.