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

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that the requested procedure is medically 
necessary for the enrollee. The Plan denied your request. The Plan says this procedure is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is considered experimental. Therefore, the reviewer found 
that the Intracept procedure is not 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thermal destruction of intraosseous basivertebral nerve (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93923 and 93923-59 billed for date of service May 31, 
2022. 
 
You asked the Plan to pay for codes 93923 and 93923-59. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says codes 93923 and 93923-59 billed for date of 
service May 31, 2022, are not supported in the medical record. Other billed codes for this date have been paid. 
 
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 93923 is Complete bilateral noninvasive physiologic 
studies of upper or lower extremity arteries, 3 or more levels (e.g., for lover extremity: ankle/brachial indices at 
distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements 
with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at 
distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or 
more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with 
provocative functional maneuvers (e.g., or measurements with reactive hyperemia) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for codes 93923 and 93923-59. Our reviewer says that codes 
93923 and 93923-59 billed for date of service May 31, 2022, are not supported in the medical record. Our 
reviewer found the procedure report does not support a bilateral noninvasive physiologic study.  The report 
cannot be cited for bilateral studies. In this case there is a more appropriate code to report for services provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 93923 and 93923-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for codes 93923 and 93923-59 billed for date of service May 31, 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 enrollee requires inpatient acute rehabilitation in 
an effort to facilitate increased independence and return home and to her community with improved quality of 
life. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 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 that the clinical documentation does not specify functional impairments or active 
medical comorbidities. There is no evidence that the enrollee would tolerate 15 hours of therapy per week, and 
the enrollee does not require inpatient hospitalization for close medical monitoring during a 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 the interdental fixation device rendered on March 2, 2022. 
 
You asked the Plan to pay for these services. You say that the services are covered by Medicare. The Plan 
denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found there is no indication of a dental 
procedure performed to treat temporo-mandibular joint disorder (TMJ) in the submitted documentation. The etiology appears to be related to previous dental procedures according to the documentation. A diagnosis of 
capsulitis and subluxation was indicated. The services were 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 pay for the interdental fixation device rendered on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Percepta Bronchial Genomic Classifier testing (81479) 
provided on June 22, 2022. 
 
You asked the Plan to pay for Percepta Bronchial Genomic Classifier testing. You say that this test was 
medically necessary and appropriate. The Plan denied your request. The Plan says the criteria for coverage of 
this test are not met, as the enrollee was already considered at high risk of malignancy prior to testing. 
 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 Percepta Bronchial Genomic Classifier 
testing. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the LCD does not provide coverage for Percepta 
Bronchial Genomic Classifier testing for enrollees with High Pre-Test Risk. Consequently, the enrollee in this 
case would not qualify for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Percepta Bronchial Genomic Classifier testing have not been met. Therefore, 
we decided that the Plan does not have to pay for Percepta Bronchial Genomic Classifier testing (81479) 
provided on June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power 
wheelchair. 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. Based on 
this information, we decided that Medicare rules for coverage of a power seat elevation feature have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) 
for a power wheelchair.
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no advantage in transferring the enrollee to the LTACH. The enrollee can 
remain at the current acute care hospital (ACH) until such time no acute services are required. The enrollee can 
then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 
 
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 selective catheter placement with moderate sedation 
provided to the enrollee on April 7, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported properly. 
 
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 the denied codes is: 
 
CPT 99153: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; each additional 15 minutes intraservice time (List separately in addition to code for 
primary service) 
 
CPT 36223: 
 
Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography 
of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, 
includes angiography of the extracranial carotid and cervicocerebral arch, when performed 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
support using procedure code 36223 with two units. There would be an appropriate modifier -50 that could be 
used for one unit. 
 
Additionally, we find that payment for CPT code 99153 is not supported. Specifically, there is no separate 
payment to the physician for CPT code 99153 when performed in the facility setting. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for selective catheter placement with moderate sedation provided to the enrollee on April 7, 2022.
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 IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says rules for IRF care 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 that the enrollee is medically stable and does not need a physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee needs routine physical therapy 
and occupational therapy but does not need 3 hours a day for 5 days a week of therapies with multidisciplinary 
approach 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI), spinal canal and
contents, thoracic; (72146) and MRI, spinal canal and contents, cervical (72141) provided to the enrollee on
May 18, 2021.
You asked the Plan to pay for these services. You say that the services should be paid. The Plan denied your
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied. However, such denials may be appealed.
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were
reimbursed by the Plan on June 7, 2021. Comparison of the two claims shows these are exact duplicates.
There is no evidence presented to support that the billed items/services were provided twice on the same date.
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore,
we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI), spinal canal and
contents, thoracic; (72146) and MRI, spinal canal and contents, cervical (72141) provided to the enrollee on
May 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse an additional amount for the transplant related lodging,
meals and transportation, per diem, (S9975) provided from February 8, 2022, to February 11, 2022.
You asked the Plan to reimburse an additional amount for the transplant related lodging, meals and
transportation, per diem. You say that only $.05 per mile was reimbursed for your 666.4 miles, for a total of
$118.80 and should have received more. The Plan denied your request. The Plan says the claim processed
correctly.
The Internal Revenue Service (IRS) website shows that rate for 2022 is 18 cents per mile. This accounts for not
only gas, but tolls and wear and tear on the vehicle. 666.4 miles travelled times 18 cents equals $119.95. The
Plan has reimbursed you this amount. Therefore, we decided that the Plan does not have to reimburse an
additional amount for the transplant related lodging, meals and transportation, per diem, (S9975) provided from
February 8, 2022, to February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 3 sensor. The Plan denied your request. The Plan says 
Medicare does not cover the FreeStyle Libre 3 device because it does not meet the definition of durable 
medical equipment. The Plan also says the FreeStyle Libre 3 is not primarily medical in nature because there is 
no associated receiver or insulin infusion pump use. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred. 
 
We looked at the file and Medicare rules. Specifically, the Plan only covers Abbott and Lifescan branded 
glucometers, diabetic test strips, lancets, control solutions and continuous glucose monitoring devices. Based 
on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 3 sensor have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography/computed tomography 
(PET/CT) scan. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the intended exam is not the one that was ordered. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that myocardial 
perfusion PET scans are indicated when there is an abnormal or non-diagnostic nuclear medicine stress test. 
There is no report of such a result in the submitted records. Additionally, the correct CPT code for the 
requested test would be CPT 78492. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve positron emission tomography/computed tomography (PET/CT) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient care at the current hospital and can remain there until ready for transfer or 
discharge. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve a PET scan of the brain. 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 an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both Alzheimer's disease (AD) and frontotemporal disorders (FTD). 
 
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 PET scan of the brain. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found in this case the enrollee is not 
readily noted to meet diagnostic criteria for either AD or FTD (let alone both) in the record provided. As the 
enrollee does not meet diagnostic criteria for both AD and FTD based on the medical records provided for 
review the initial requirement for coverage of a PET/computed tomography (CT) scan would not otherwise be 
met/satisfied at this time. As such it cannot be said that the requirements of the NCD have been satisfied. 
 
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 28, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As such, when billed with a facility place of service, the profession 
interpretation must be billed with modifier -26 for payment to be considered. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on March 28, 2022.