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

 
We decided that the Plan does not have to waive the copayment for the office visit provided on September 13, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that this should be an annual wellness 
visit. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for each primary care provider visit or telehealth visit for Medicare-covered benefits.  
 
You have been asked to pay a $5 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the office visit provided on September 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on May 9, 2022. 
 
You asked the Plan to pay for the provided equipment. You say that you needed the device as quickly as 
possible. The Plan denied your request. The Plan says you must go to a supplier that is enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
The file shows that you received a continuous positive airway pressure (CPAP) device and related supplies. A 
review of records indicates that the provider at issue is not enrolled in the Medicare program. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the durable medical equipment provided on May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) provided on 
August 17, 2022. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that this item was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The date of service billed (August 17, 2022) does not 
match the date on the proof of delivery (October 22, 2022). The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for a continuous glucose monitor (K0553, K0554) provided on August 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF stay will help address the enrollee's mobility 
and functional deficits and therapy is needed to prevent regression of function and independence. The Plan 
denied your request. The Plan says the enrollee does not meet the medical necessity criteria for admission to an 
IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back surgery at the level of L5-S1 posterior fusion 
(22632 x 2 units) with PEEK spacer (22853 x 2), stereotactic computer-assisted navigational procedure (61783 
x 2 units), and inpatient level of care. 
 
You asked the Plan to pre-approve a back surgery. You say that the services are medically necessary. 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 a back surgery. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documented spinal instability or stenosis at L5-S1 causing neurologic symptoms. 
 
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 back surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a back surgery at the level of L5-S1 posterior fusion (22632 x 2 units) with PEEK spacer (22853 x 2), stereotactic computer-assisted navigational procedure (61783 x 2 units), and inpatient level of 
care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service October 25, 
2021. 
 You asked the Plan to pay for procedure code 87640. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 
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 87640 
is a column II code to column I code 87641. 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 procedure code 87640 billed for date of service October 25, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires skilled nursing services for 
their complex wound care and continued therapies due to their debility and weakness. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for SNF care. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/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 SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you did not call for the ambulance and say 
that a bystander must have called. You say that you should not have to pay the ambulance bill. The Plan denied 
your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 15, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 10, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service October 10, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary and the enrollee's needs can 
be met 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. Our 
physician reviewer found that you do not have complex nursing or rehabilitation needs. 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 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyndamax. 
 
You asked the Plan to pre-approve Vyndamax. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vyndamax.  
 
Benefits for Vyndamax may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 SNF admission is necessary for the enrollee to be 
able to go home to live independently. The Plan denied your request. The Plan says the denial of SNF care is 
correct. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the procedure is medically necessary 
for the enrollee's condition and relief of her current symptoms. The Plan denied your request. The Plan says 
unproven and not medically necessary procedures are not covered by Medicare. 
 
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 the intracept procedure is experimental and investigational. More research is needed 
due to insufficient evidence of 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 a thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 22, 2022, billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401, 
and 0031U. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and should be paid. 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 
May 22, 2022, billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 
81328, 81355, 81335, 81401, and 0031U.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 7, 2022, to 
January 10, 2022. 
 
You asked the Plan to pay for the home health services. You say that the date of service was found to be 
correct. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue was 
not billed as the first date in 2022 as required. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from January 7, 2022, to January 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided on May 13, 2022, billed with codes 37220, 
37233, and 37253. 
 
You asked the Plan to pay for codes 37220, 37233, and 37253. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that providers must 
report the actual number of units provided for each procedure code. 
 
In this case, the CPT Code Manual definition of code 37220 is revascularization, endovascular, open or 
percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty. 
 The CPT Code Manual definition of code 37233 is revascularization, endovascular, open or percutaneous, 
tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same 
vessel, when performed (List separately in addition to code for primary procedure). 
 
The CPT Code Manual definition of code 37253 is intravascular ultrasound (noncoronary vessel) during 
diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; 
each additional noncoronary vessel (List separately in addition to code for primary procedure).  
 
We find that CPT codes 37220, 37233, and 37253 are not supported in the medical record. Specifically, the 
operative report did not include documentation of an open or percutaneous endovascular revascularization for 
the initial vessel, of a unilateral iliac artery, with transluminal angioplasty; therefore, code 37220 cannot be 
verified.  
 
The operative report did not include documentation of an open or percutaneous endovascular revascularization, 
of unilateral tibial/peroneal artery, for each additional vessel, with atherectomy, including angioplasty within 
the same vessel, when performed (listed separately in addition to code for primary procedure); therefore, code 
37233 cannot be verified 
 
We find that three (3) units of CPT code 37253 are not supported in the medical record. 
 
Based on this information, we decided that Medicare rules for coverage of codes 37220, 37233, and 37253 
have not been met. Therefore, we decided that the Plan does not have to pay for services provided on May 13, 
2022, billed with codes 37220, 37233, and 37253.
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 member does not meet the Medicare
criteria for LTACH services. The Plan denied your request. The Plan says you would like to request
reconsideration of the denied authorization.

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 the medical record does not indicate that the enrollee requires services that she is not
currently receiving. The enrollee still requires acute care services before transitioning to a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
29, 2022. 
 You asked the Plan to pay for procedure code 76641. 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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 29, 2022.