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

 
We decided that the Plan does not have to pay for code 99214 billed for date of service June 21, 2022. 
 
You asked the Plan to pay for code 99214. You say that the medical records support the code billed. The Plan 
denied your request. The Plan says code 99214 is not supported by the medical record. The medical records 
don't support a moderate level of medical decision making or total time required of the code 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 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 99214. Our reviewer says that code 99214 is not 
supported by the medical record. Our reviewer found the documentation is for a subsequent visit with an 
established patient.  The records indicate that the patient was seen via telemedicine, but that urine and vital 
signs were obtained.  It is difficult to determine what information is obtained during this visit, versus cut/pasted 
from previous encounters.  The assessment and plan appear to be routine and rote.  As such, a moderate level of 
medical decision making is not documented, and the billing of CPT 99214 is not 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 code 99214 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99214 billed for date of service June 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 4, 2023, to June 1, 
2023. 
 You asked the Plan to pay for the home health services. You say that this NOA was submitted late due to an 
error in the payer submission. The Plan denied your request. The Plan says the NOA was not received timely. 
As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 3, 2023. The NOA was not received by the Plan until June 14, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from May 4, 2023, to June 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve the genicular radiofrequency ablation.. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is considered experimental. 
 
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 radiofrequency ablation.. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental. 
 
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 radiofrequency ablation. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the genicular radiofrequency ablation.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that 
Aranesp is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's required drugs Retacrit or Procrit. Also, the documentation does not support that the Plan's required 
drugs would likely be less effective or would likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on April 3, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a flex-walk system or equal (L5981). 
 
You asked the Plan to pre-approve a flex-walk system or equal. You say that you would like the denial to be 
overturned as the objective facts and evidence compel the conclusion that this component is medically 
necessary, and the provided documents meet all Medicare documentation guidelines showing why they are 
needed over a simpler foot. The Plan denied your request. The Plan says that the request does not meet the 
Medicare or health plan coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a flex-walk system or equal (L5981) is covered for 
beneficiaries whose functional level is 3 or above. 
 
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 flex-walk system or equal. Our 
reviewer says that this request is medically reasonable and necessary. Our physician reviewer found not only 
does the medical record go above and beyond in satisfying Medicare policy by demonstrating you have K3 
level potential and have specific needs for the requested components, but the Plan also attempts to create a 
more restrictive policy for defining K3 function than Medicare policy would allow. Our reviewer found that 
regarding the criteria for coverage of the requested component, no further specific documentation is required in 
the LCD, the Policy Article, or any of the relevant Medicare manuals because Medicares policy recognizes 
that flex-walk feet are part of the basic standard of care for all community K3 ambulators given that the 
evidence of their benefits and superiority to less sophisticated alternatives are so well proven and long standing.  
In your case, and all comparable K3 ambulators, lesser devices simply cannot meet your functional needs and 
amount to substandard 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 a flex-walk system or equal have been met. Therefore, we decided that the Plan 
has to pre-approve a flex-walk system or equal (L5981).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 69210 billed for date of service May 18, 2023. 
 
You asked the Plan to pay for code 69210. You say that documentation supporting this claim has been 
provided. The Plan denied your request. The Plan says the billing of code 69210 is not supported by 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. 
 
In this case, the CPT Code Manual definition of code 69210 is Removal impacted cerumen requiring 
instrumentation, unilateral. 
 
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 69210. Our reviewer says that code 69210 is not 
supported by the medical records. Our reviewer found the procedure report does not include sufficient documentation to confirm this procedure was performed.  For CPT 69210, the provider must examine the pinna 
and external auditory canal, grasp the pinna and expose and open the external auditory canal, and position the 
instrument of magnification. Then, the provider must remove cerumen using a variety of instrumentation 
including cerumen curettes, spoons, suctions, and microforceps.  Therefore, this procedure code cannot be 
verified. 
 
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 69210 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 69210 billed for date of service May 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
   
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, and 88360 billed for date of 
service May 12, 2023. You asked the Plan to pay for procedure codes 88341, 88342, and 88360. You say that you are entitled to 
payment. The Plan denied your request. The Plan says the codes are included in the skilled nursing facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT codes 88341, 88342, and 88360 have a Professional/Technical indicator of 1. This means that 
CPT codes 88341, 88342, and 88360 has both a professional and technical component. In this case, an 
appropriate modifier was not billed. 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 codes 88341, 88342, 
and 88360 billed for date of service May 12, 2023.
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 you are still suffering with medical issues and have 
not been released to leave the facility yet by your care team. The Plan denied your request. The Plan says you 
no longer require skilled nursing needs and have declined further therapy services for several days. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99219 billed for date of service June 1, 2021. 
 
You asked the Plan to pay for code 99219. You say that these services were medically necessary and billed 
correctly. The Plan denied your request. The Plan says you billed this code with an incorrect Place of Service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99219 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99219 billed for date of service June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee needs the non-invasive 
home ventilation unit to continue quality of life. The Plan denied your request. The Plan says a home ventilator 
is not medically necessary for this patient because their needs can be met with an alternative device such as a 
BiPAP device with average volume-assured pressure support (AVAPS).   
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
was recently hospitalized for exacerbation of diastolic heart failure and presumed exacerbation of COPD. 
However, there are no pulmonary function tests to confirm airways obstruction or assess the severity of the 
COPD. There are also diagnosis of obstructive sleep apnea and obesity hypoventilation syndrome. The enrollee 
has reportedly refused a home ventilator in the past and has been noncompliant with a CPAP. Also, there is no 
diagnosis of thoracic restrictive disease or neuromuscular disease. Also, arterial blood gas (ABG) analysis on 
admission was consistent with acute on chronic hypercarbic respiratory failure, and the enrollee improved with 
diuresis and BiPAP. Furthermore, there is no ABG analysis done while stable, and not in pulmonary edema to 
confirm chronic carbon dioxide retention. If that is present, the enrollee may benefit from a BiPAP with 
AVAPS during sleep as an outpatient. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral L2 radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. The Plan denied your request. The Plan says a 
bilateral L2 radiofrequency ablation 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 radiofrequency ablation. Our 
reviewer says that a bilateral L2 radiofrequency ablation is not medically necessary. Our physician reviewer 
found that the enrollee has already had two radiofrequency ablations within the same 12 months. Therefore, the 
enrollee does not meet the 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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bilateral L2 radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 81479 billed for date of service April 18, 2023. 
 
You asked the Plan to pay for code 91479. You say that this testing is not experimental, and it is approved by 
Medicare. The Plan denied your request. The Plan says code 81479 is not supported by the medical records. 
The records show that a hematology profile plus was ordered and performed. As a result, code 81455 should 
have been billed instead. 
 
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 81479 is Unlisted molecular pathology 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 code 91479. Our reviewer says that code 81479 is not supported by the medical record. Our reviewer found the enrollee in this case had a diagnosis of peripheral T-
cell lymphoma; next generation sequencing was performed on a bone marrow specimen. The test was 
described as: This is a comprehensive molecular profile which uses next generation sequencing (NGS), 
Sanger Sequencing and fragment length analysis testing to identify molecular abnormalities (including SNVs, 
INDELS, CNVs, Fusions, HPV, EBV, and IgVH) in DNA of 179 genes and RNA in 1501 genes associated 
with hematologic neoplasms, including leukemia, lymphoma, myeloma, and MDS. Whenever possible, clinical 
relevance and implications of detected abnormalities are described below.  
 
CPT code 81455 is defined as a targeted genomic sequence analysis panel, solid organ or hematolymphoid 
neoplasm or disorder, 51 or greater genes, interrogation for sequence variants and copy number variants or 
rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined 
DNA and RNA analysis. In this case CPT code 81455 more specifically and accurately represents the 
procedure performed, thus CPT code 81479 is not 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 code 91479 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 81479 billed for date of service April 18, 2023.