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

 
We decided that the Plan does not have to pay for procedure codes 95907, 95886, and 95937 billed for date of 
service August 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were ordered as a surgical 
requirement. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95907 is nerve conduction studies; 1-2 studies. The CPT 
Code Manual definition of code 95886 is needle electromyography, each extremity, with related paraspinal 
areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or 
more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in 
addition to code for primary procedure). The CPT Code Manual definition of code 95937 is neuromuscular 
junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. 
 
We find that CPT codes 95907 and 95886 are not supported in the medical record. Specifically, the records do 
not describe the procedure codes as billed. Train of Four Testing does not fit the criteria set by CMS and 
Insurance Carriers for CPT 95937. There is no separate code for Train of Four Monitoring, therefore, it would 
be inappropriate to bill the Neuromuscular Junction Testing code for Train of Four Monitoring. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 95907, 95886, and 95937 billed for date of 
service August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site 
(D4266), surgical placement of implant body (D6010), surgical access to an implant body (D6011), bone 
replacement graft for ridge preservation - per site (D7953) all for tooth #8, and drugs or medicaments 
dispensed (D9630). 
 
You asked the Plan to pre-approve codes D4266, D6010, D6011, D7953 and D9630. You say that front tooth 
#8 was removed and part of the tooth was left inside. You also say that the dentist recommends removing what 
is left of the tooth and replace it with an implant. The Plan denied your request. The Plan says these services 
are not covered under the benefit package. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regeneration - resorbable barrier, per site (D4266), surgical placement of implant body (D6010), 
surgical access to an implant body (D6011), bone replacement graft for ridge preservation - per site (D7953) all 
for tooth #8, and drugs or medicaments dispensed (D9630).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve angiogram and revascularization coded with CPT codes 
(CPT(s) 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231) 
 
You asked the Plan to pre-approve the surgical procedure. You say that the requested items/services are not 
considered medically reasonable and necessary in this case. The Plan denied your request. The Plan says the 
request for these procedures (CPT codes 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 
37231) is denied as they are not medically necessary for your condition. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the record indicates that the enrollee has peripheral vascular disease. The 
record indicates that the enrollee had normal ankle brachial indices and pulse wave forms. The record provided does not document the presence of limb threat, claudication limiting activities, or the failure of conservative 
therapy. The records provided are insufficient to establish the medical necessity of the requested service. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve angiogram and revascularization coded with CPT codes (CPT(s) 37220, 37221, 
37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical additional radiographic image 
(D0230) provided on November 2, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the intraoral-periapical 
radiographic image has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral-periapical radiographic image provided was exhausted on date of service 
November 2, 2022. Specifically, the Plan contract states that one periapical radiographic image is covered per 
year. You received two intraoral-periapical radiographic images on this day. The Plan issued payment for one 
of the radiographic images provided. Therefore, you have exhausted the allowable benefit for this service. 
Therefore, we decided that the Plan does not have to pay for the intraoral-periapical additional radiographic 
image (D0230) provided on November 2, 2022.
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 the enrollee meets the admission criteria. 
The Plan denied your request. The Plan says the plan will continue to cover medically necessary acute and 
critical care at the current facility until the enrollee's condition is stable for transfer to an alternate level of care, 
a skilled nursing facility, or until the clinical circumstances change such that LTACH may be reconsidered. 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current location is recommended. 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93280 and 99233 billed for date of service 
July 13, 2022, to July 14, 2022. 
 
You asked the Plan to pay for procedure codes 93280 and 99233. The Plan denied your request. The Plan says 
payment for codes 93280 and 99233 is bundled. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93280 
is a column II code to column I code 33208. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
 
Medicare rules also say that the Medicare approved amount for global surgery procedures includes payment for 
services related to the surgery when furnished by the physician who performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the code 99233 is included in the global surgery 
payment for the procedure (33208) provided on July 14, 2022, which has a 90-day global period. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 93280 and 99233 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 93280 and 99233 billed for 
date of service July 13, 2022, to July 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization. You say that the records provided support the need 
for the requested treatment. The Plan denied your request. The Plan says left heart catheterization is not 
recommended unless there is evidence of at least mild ischemia on imaging or significant obstructive coronary 
artery disease on coronary computed tomographic angiography (CCTA). 
 
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 left heart catheterization. Our reviewer 
says that left heart catheterization services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee had a negative radionuclide stress test and left ventricle (LV) 
ejection fraction is normal. The medical records provided do not support the rationale for the requested 
invasive imaging study. Guidelines do not support a need for cardiac catheterization in this setting. As a result, 
at this time cardiac catheterization would not be considered medically appropriate and necessary in this 
enrollee's clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization.
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 you need the IRF the level of rehabilitation to regain 
muscle strength in your knees, to return home independently. The Plan denied your request. The Plan says our 
records do not show you need an intensive team for your care. 
 
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 there is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intermittent urinary catheter, with insertion supplies 
(A4353) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve urinary catheter supplies. You say that you disagree with the denial. The 
Plan denied your request. The Plan says you must use network providers to get your medical care and services. 
The Plan has confirmed an in-network DME provider that can provide the urinary catheter supplies. Even 
though they are more than 30 miles from you, they will ship the urinary catheter supplies to you within a week. 
 
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 
intermittent urinary catheter, with insertion supplies (A4353) to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have a diagnosis of prostate cancer. 
Magnetic resonance imaging (MRI) does not show spread beyond the prostate. There is insufficient date to 
support that the requested proton beam therapy is superior to intensity modulated radiation therapy (IMRT). 
The recent National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) 
guidelines state that proton beam therapy does not offer clinical advantage over other forms of definite 
treatment. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy.
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 transfer to an LTACH is medically 
reasonable and necessary. The Plan denied your request. The Plan says transfer to an LTACH is not medically 
necessary in this case, as the enrollee can receive the necessary care in a less intensive setting. 
 
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 that the enrollee was admitted to the acute care hospital with septic shock, 
pneumonia, cellulitis, and respiratory failure requiring antibiotics, emergent cricothyroidotomy and 
tracheostomy placement, mechanical ventilation support and fluids, and complicated by encephalopathy and drug allergy/rash. Recent notes describe the enrollee with improved kidney function, stable vitals, and 
tolerating tracheostomy collar trials. At this time, the enrollee appears to be more stable and is improving and 
should only require short-term additional acute care services that can safely be provided at the current facility 
until more stable and appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not already available and covered at the current facility. Transfer to the LTACH is not 
medically necessary as it would not be clinically advantageous. Completion of treatment at the current facility 
is recommended in this case. 
 
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 the genetic testing provided on July 28, 2022, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 81407, 
81408 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 28, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 
81404, 81405, 81406, 81407, 81408 and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is founded on 
30-years of basic science research linking Modic changes to chronic low back pain. The Plan denied your 
request. The Plan says the requested procedure is unproven and not medically necessary as there is insufficient 
evidence of efficacy. 
 
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 Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental in living humans who have back pain. More 
research on live subjects is needed to show safety and efficacy. 
 
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 the Intracept procedure.
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 had half of his lungs removed and the 
doctors caring for him believe he needs to be in an IRF so they can properly monitor him. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for pleural effusion. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.