Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patient programmer, neurostimulator (C1787), Lead, 
neurostimulator (implantable) (C1778), a generator, neurostimulator (implantable), non-rechargeable (C1767) 
and an open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory 
sensor electrode or electrode array (64582). 
 
You asked the Plan to pre-approve a nerve stimulator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee does not show that she has a body mass index (BMI) under 32. 
 
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 nerve stimulator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee meets the coverage criteria for 
the requested nerve stimulator, as the BMI exceeds 35 kg/m2. The LCD states that hypoglossal nerve 
neurostimulation is considered not medically reasonable and necessary when any of the following 
contraindications are present, BMI equal to or greater than 35. 
 
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 nerve stimulator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a patient programmer, neurostimulator (C1787), Lead, neurostimulator (implantable) 
(C1778), a generator, neurostimulator (implantable), non-rechargeable (C1767) and an open implantation of 
hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode 
array (64582).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 billed for date of service February 14, 
2022. 
 
You asked the Plan to pay for procedure code 64488. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 64488 is bundled into payment for code 43644.  
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 64488 
is a column II code to column I code 43644. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 64488 billed for date of service February 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service October 20, 
2021. 
 
You asked the Plan to pay for procedure code 97110. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 97110 is bundled into payment for code 92526.  
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 97110 
is a column II code to column I code 92526. 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 97110 billed for date of service October 20, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74170 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 74170. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 74170 is bundled into 
payment for code 74178. 
 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 74170 
is a column II code to column I code 74178. 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 74170 billed for date of service March 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 25, 
2022. 
 
You asked the Plan to pay for procedure code 70450. 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 June 25, 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 you are requesting inpatient rehabilitation services. 
The Plan denied your request. The Plan says you could receive care in another setting such as skilled nursing 
facility, outpatient setting or home health 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 are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 pay for cytogenetic studies for oncologic or inherited disorders 
(CPT 88291) provided on March 30, 2022. 
 
You asked the Plan to pay for cytogenetic studies for oncologic or inherited disorders. The Plan denied your 
request. The Plan says the requested cytogenetic studies does not meet the Medicare coverage criteria. 
 The Plan follows Medicare rules.  
 
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 cytogenetic studies for oncologic or 
inherited disorders. Our reviewer says that cytogenetic studies for oncologic or inherited disorders is not 
medically necessary. Our physician reviewer found that in this case, the enrollee's condition related to the 
service in dispute: Small cell B-cell lymphoma, unspecified site. The review has determined that the requested 
cytogenetic studies do not meet the Medicare 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 cytogenetic studies for oncologic or inherited disorders have not been met. 
Therefore, we decided that the Plan does not have to pay for cytogenetic studies for oncologic or inherited 
disorders (CPT 88291) provided on March 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 4, 2022, 
through February 2, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. The Plan did not 
receive an NOA for the admission date of January 4, 2022. Therefore, we decided that the Plan does not have 
to pay for the home health services provided from January 4, 2022, through February 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on 
Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements. 
 
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 enrollee was admitted to the acute hospital on October 9, 2022, as a transfer from 
an outside hospital for intraventricular hemorrhage due to left thalamic arteriovenous malformations rupture. 
As of November 8, 2022, the enrollee is on tracheostomy collar, requiring suctioning every 2-4 hours, and on 
continuous tube feeds. The enrollee has not required prolonged mechanical ventilation. There is no 
documentation of multiple unsuccessful weaning attempts. There is also no documentation that the enrollee is 
capable of being weaned at this time.  
 The enrollee is receiving appropriate care at the present setting. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where they are currently receiving 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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has open wounds due to not being 
rehabilitated consistently and needs IRF services in order to walk again. The Plan denied your request. The 
Plan says the request is not medically necessary. 
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says unauthorized, out-of-network services are 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. 
 
Neither your lab nor the ordering provider is 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 lab services provided on April 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tolterodine 2mg tablet medication. 
 
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the 
enrollees contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Tolterodine 2mg tablet 
medication.  
 Benefits for this medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99212-GQ billed for date of service June 6, 2022. 
 
You asked the Plan to pay for code 99212-GQ. You say that the medical records support payment. The Plan 
denied your request. The Plan says you appended the GQ modifier inappropriately. 
 
The Plan must follow Medicare rules. Medicare rules say that the GQ modifier is to be used for asynchronous 
telecommunications services affiliated with a federal telemedicine demonstration program conducted in Alaska 
or Hawaii. The records do not indicate that the services rendered were related to telemedicine services 
conducted in Alaska or Hawaii, so another modifier should have been used. Therefore, we decided that the Plan 
does not have to pay for code 99212-GQ billed for date of service June 6, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management (EM) service provided on July 8, 2022, 
billed with code 99214-25. 
 
You asked the Plan to pay for the billed EM service. You say that this should be paid per the records submitted. 
The Plan denied your request. The Plan says that this service was provided within the 90 days following a 
major surgery. Therefore, no separate payment is allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that only postoperative visits that are related to 
recovery from the surgery are included in the global package. Treatment of the underlying medical condition is 
not included in the package. Separate payment is allowed for services billed with modifier -25. 
 
We looked at the file and Medicare rules. Review of the progress note indicates that this visit was to check on 
the enrollee's condition since starting a specific therapy. It is not shown to be directly related to the recovery of 
the pacemaker replacement surgery, but treatment for the underlying medical condition. The code was correctly 
billed with modifier -25 for this situation. Therefore, we decided that the Plan has to pay for the evaluation and 
management (EM) service provided on July 8, 2022, billed with code 99214-25.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) implant trial. 
 
You asked the Plan to pre-approve a SCS implant trial. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a SCS implant trial. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the review has determined that the 
enrollee has not received maximal medical therapy prior to a spinal cord stimulator implant trial. The review 
has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 SCS implant trial have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a spinal cord stimulator (SCS) implant trial.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Nodify CDT testing (81599) provided on June 7, 2021. 
 
You asked the Plan to pay for Nodify CDT testing. You say that this should be covered. The Plan denied your 
request. The Plan says this was 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 pay for Nodify CDT testing. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the submitted medical records do not document how the results of the test would be used in the 
management of the enrollee at the time of the testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nodify CDT testing have not been met. Therefore, we decided that the Plan 
does not have to pay for Nodify CDT testing (81599) provided on June 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for date of service February 23, 
2022. 
 
You asked the Plan to pay for procedure code 97110. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says payment for code 97110 is bundled into payment for code 92526.  
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 97110 
is a column II code to column I code 92526. 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 97110 billed for date of service February 23, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs acute therapy so she can regain 
full mobility and quality of life. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 25, 2022, 
through May 24, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. The billed claim is for 
a non-participating home health provider and an appropriate NOA claim was not submitted for the period of 
care and the admission date is not valid. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from April 25, 2022, through May 24, 2022.