Persius/hicric huggingface dataset:
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 this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 78-year-old male is being treated for spondylosis without 
myelopathy. He presented with chronic low back pain. Exam reveals the pain increases with both flexion and 
some extension. There is stiffness and he cannot extend past neutral. Gait is slow and deliberate. The January 
2022 MRI of the lumbar spine showed L3-4: marked narrowing of the disc space with desiccation and evolving 
discogenic endplate changes, osteochondral defects on either side of the disc space, annular bulging and facet 
arthropathy slight ident the thecal sac, in the midline the thecal sac measures 11mm, changes produce moderate 
subarticular recess and foraminal stenosis.   
However, there were/are multiple plausible pathologic sources of significant pain generation. The non-radiating 
midline back pain, the noted pain-aggravating and pain-relieving factors, along with the diminished and painful 
spinal motion (in all directions) and intact neurologic exam were/are all non-specific to any pathologic entities. 
Overall, documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of 
the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent 
pain. Documentation does not support formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Intracept intraosseous nerve ablation procedure at L3 and L4, in this case, is not medically reasonable or 
necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on January 26, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says services provided by an out-of-network provider 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physical therapy provided on January 26, 2021, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for therapeutic exercises (97110) provided on August 18, 2021. 
 
You asked the Plan to pay for therapeutic exercises. You say that these services were necessary and were billed 
appropriately. The Plan denied your request. The Plan says that this claim was billed incorrectly. 
 
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. Specifically, the Plan states that they received and reviewed medical records for 
this case. No medical records were forwarded to us for review. Without medical records, we cannot verify the 
Plans argument for denial. Therefore, we decided that the Plan has to pay for therapeutic exercises (97110) 
provided on August 18, 2021.  
 
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 a FreeStyle Libre 14 Day Sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 14 Day Sensor. You say that the enrollee has been using 
this sensor since 2019 and didn't have any problems with it. You say that, whether the enrollee uses a sliding 
scale with his insulin or not, it is necessary for him to monitor his blood glucose daily. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a FreeStyle Libre 14 Day Sensor have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 14 Day Sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunohistochemistry or immunocytochemistry, per 
specimen; each additional single antibody stain procedure (list separately in addition to code for primary 
procedure) (88341) provided August 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you ask that this claim be reopened and 
reprocessed for payment of all charges. The Plan denied your request. The Plan says this screening testing is 
not a Medicare benefit. Screening services such as pre-symptomatic genetic tests and services used to detect a 
disease predisposition are not a benefit and are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Immunohistochemistry or immunocytochemistry, is being requested solely 
for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided 
that the Plan does not have to pay for immunohistochemistry or immunocytochemistry, per specimen; each 
additional single antibody stain procedure (list separately in addition to code for primary procedure) (88341) 
provided August 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that if the trial is successful, permanent 
placement will follow. You say that the requested procedure is medically necessary. The Plan denied your 
request. The Plan says the enrollee had a spinal cord stimulator placed after back surgery in 2019 which did not 
relieve his pain. 
 
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 a spinal cord stimulator. Our reviewer 
says that a spinal cord stimulator is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence of recent conservative therapy and there is an out-of-date 
psychological evaluation. DRG stimulation is an experimental/investigational procedure. The enrollee has not 
had recent conservative therapy trials. There are other evidence-based interventions available 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatry visit provided on September 28, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON psychiatry visit. You say that authorization is not required for this 
service. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan.  The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the psychiatry visit provided on September 28, 
2021, by an out-of-network (OON) provider.
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 October 
25, 2021. 
 
You asked the Plan to pay for the services provided. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the provider type is excluded from Medicare coverage. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The records show that the services at issue were provided by a licensed 
professional counselor. This type of provider is not eligible to participate in Medicare. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided on 
October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 12, 
2021. 
 
You asked the Plan to pay for procedure code 99100. You say that you have submitted the claim with 
supporting medical records. The Plan denied your request. The Plan says no separate payment can be made for 
this code. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for codes that have a status indicator of 
"B" on the Medicare Physician Fee Schedule Database is always bundled into payment for other services.  No 
separate payment is ever made for these codes. Procedure code 99100 has a status indicator of "B" on the 
Medicare Physician Fee Schedule Database.  Therefore, we decided that the Plan does not have to pay for 
procedure code 99100 billed for date of service February 12, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 3, 2021, to 
March 9, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the level of care is not supported. 
 
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 the enrollee presented to the emergency department on March 3, 2021 with obstipation and 
poor po intake. The reviewer found that the enrollee was evaluated and admitted. The reviewer found that the 
enrollee's condition stabilized and improved and was discharged home when considered medically stable on 
March 9, 2021. The review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 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 March 3, 2021, to March 9, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting (76377), 
the Moderate sedation services (99152), and the Computed tomography (CT) scan (76380) provided on July 9, 
2021. 
 
You asked the Plan to pay for codes 76377, 99152, and 76380. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 76377 is not supported in the medical record. Specifically, the governing LCA includes 
a list of secondary diagnosis codes which are required to support the medical necessity of CPT code 76377. 
This claim has not been billed with an appropriate secondary diagnosis code. 
 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99152 
is a column II code to column I code 77300. We have also confirmed that code 76380 is a column II code to 
column I code 37243. This claim has not been billed with an appropriate modifier to bypass the edits. Based on 
the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not 
have to pay for the 3D rendering with interpretation and reporting (76377), the Moderate sedation services 
(99152), and the Computed tomography (CT) scan (76380) provided on July 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus test (87635) and critical care, first hour, 
(99291) provided on September 26, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 4, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the coronavirus test 
(87635) and critical care, first hour, (99291) provided on September 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an anesthetic injection (64447) provided on August 19, 2021. 
 
You asked the Plan to pay for anesthetic injection 64447. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
code 64447 has a Procedure-to-Procedure (PTP) edit of 0 with code 43753 so is never separately payable.  
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 64447 
is a column II code to column I code 43753. 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. Therefore, we 
decided that the Plan does not have to pay for an anesthetic injection (64447) provided on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that these lab services were medically necessary. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with POS code 99, which 
indicates that the specimen was obtained in 'Other Place of Service'.  However, the records show that the 
specimen was collected in an office setting, which would mean that the POS code billed should have been POS 
11. Therefore, we decided that the Plan does not have to pay for lab services provided on April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 4, 2021. 
 
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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device (E0673), provided on 
June 3, 2021. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device 
(E0673), provided on June 3, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollees ongoing skilled therapy and nursing needs can be 
provided at a lower level of 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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for urinary tract infection. Your 
medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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.