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

 
We decided that the Plan has to pay for codes 87635, G2023, and 93005 provided on May 9, 2022. 
 
You asked the Plan to pay for codes 87635, G2023, and 93005. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that code G2023 has a status code of "B". 
 
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. Review of the file shows that the Plan states that their system created edit 62 
due to code G2023 having a status code of B. The documentation does not include why the other codes are 
not payable as billed. The Plan states that this claim not eligible for payment based on billing guidelines but 
does not include rationale for denial. This means the Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for codes 87635, G2023, and 93005 provided on May 9, 2022.  
 
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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for air ambulance transportation (A0430, A0435) provided on August 5, 
2020. 
 
You asked the Plan to pay for air ambulance transportation. You say that the enrollee was told that this was the 
only facility able to provide care, and the providers assured you that this transportation would be covered. The 
Plan denied your request. The Plan says that there were multiple nearby higher acuity hospitals which would 
have been able to provide the necessary care. Transportation is only covered to the closest facility able to 
provide the necessary care. 
 
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 has provided no information regarding the closer facilities 
which would have been able to provide the necessary care. Without the information on these alternative 
facilities, we cannot verify the Plans denial. Therefore, we decided that the Plan has to pay for air ambulance 
transportation (A0430, A0435) provided on August 5, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 30, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 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 genetic testing at issue in this appeal was 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 the genetic 
testing provided on June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70470 billed for date of service May 11, 
2022. 
 
You asked the Plan to pay for procedure code 70470. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70470 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 70470 
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 70470 billed for date of service May 11, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee is medically stable and does not need PM&R 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. No rehab nursing needs identified or documented. At the current functional 
level, the enrollee does not need 3 hours a day x 5 days a week of therapies with multidisciplinary approach in 
an IRF. Document does not support medical necessity for admission to an IRF. The enrollee has no current 
medical complexity or rehab nursing needs. The enrollee's rehab needs can be safely met in an alternate and 
low intensity setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for a pneumatic compression 
device. 
 
You asked the Plan to pre-approve the services. You say that the enrollee would face obstacles that would 
impair healing if forced to use any other durable medical equipment (DME) company. The Plan denied your 
request. The Plan says there is medically necessary care available in-network. 
 
The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a 
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating 
practitioner to avoid an adverse medical outcome. 
  
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is strong evidence in the record the necessary services are available in network. The out of network 
vendor is not medically necessary. The in-network vendor is a very well-known provider. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an out-of-network referral for a pneumatic compression device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the records support multiple procedures on 
this date of service. 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 76642 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 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service September 13, 2022.
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 7, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. 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 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat home sleep study. 
 
You asked the Plan to pre-approve the repeat home sleep study. You say that this should be reconsidered 
because you do not feel that the prior study was accurate. The Plan denied your request. The Plan says the 
enrollee had a negative home sleep study earlier this year, and the rationale for this determination is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that home sleep studies may be considered medically 
reasonable and necessary in accordance with the criteria noted 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 the repeat home sleep study. Our 
reviewer says that the requested study is not medically reasonable and necessary based on the records provided. 
Our physician reviewer found the enrollee states that they have a past diagnosis of sleep apnea but had a 
negative sleep study earlier this year. The enrollee feels that the results of that study are not correct. 
Unfortunately, the report of that study is not provided. The enrollee was unable complete an attended sleep 
study due to nocturia. Without the report, it is not possible to judge whether that study was adequate for 
diagnosis.   A repeat home PSG would be subject to the same limitations, however. There is not sufficient 
support that a home sleep study would be beneficial. 
 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 repeat home sleep study have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat home sleep study.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for subsequent nursing facility care (99309) provided on August 4, 2021. 
 
You asked the Plan to pay for nursing facility care. You say that this service was necessary and was billed 
appropriately. The Plan denied your request. The Plan says that this service has already been billed by another 
provider. 
 
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 has not included any documentation to show that this 
service has been previously paid to any provider. The Plan also did not provide a citation to support their 
argument. Therefore, we decided that the Plan has to pay for subsequent nursing facility care (99309) provided 
on August 4, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
15, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on this date 
of service. 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 15, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (88237, 88291, 88264) provided on May 11, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical records. The Plan denied your request. The Plan says that there is not enough information to 
process this claim. 
 
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 did not provide a clear explanation for denial. The records 
provided include medical records from the enrollee's treating physician, a requisition form and the results of 
testing. The Plan's denial cannot be verified as no specific rationale for denial was provided. Therefore, we 
decided that the Plan has to pay for laboratory services (88237, 88291, 88264) provided on May 11, 2022.  
 
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 procedure code 49465 billed for date of service June 29, 
2022. 
 
You asked the Plan to pay for procedure code 49465. You say that this service should be reprocessed and paid. 
The Plan denied your request. The Plan says this procedure is packaged into the global surgery period payment 
for procedure code 36558 which was provided to the enrollee on June 23, 2022. This service was not billed 
with an appropriate modifier for separate payment. 
 The Plan must follow Medicare rules. Medicare rules say that if the Field 16 entry for a code is 010, A/B 
MACs (B) do not allow separate payment for postoperative visits or services within 10 days of the surgery that 
are related to recovery from the procedure.  
 
We looked at the file and Medicare rules. The records show that Field 16 for code 36558, which was provided 
to the enrollee on June 23, 2022, is 010. This means that separate payment for postoperative visits or services 
within ten days of this service are not allowed. This service was not billed with a modifier to report an 
unrelated procedure. Based on this information, we decided that Medicare rules for coverage of procedure code 
49465 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 49465 
billed for date of service June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services (93284) provided on July 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for out-of-network services. You say that these services were medically necessary 
and reasonable. The Plan denied your request. The Plan says out-of-network care is only covered in certain 
limited circumstances which have not been met in this case. 
 
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 services (93284) provided on July 25, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (28285) provided on June 29, 2021. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 CPT code 28285 is not supported in the medical record. Specifically, this service is included in the 
global surgery package for another code billed. Based on this information, we decided that Medicare rules for 
coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay 
for surgical services (28285) provided on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized knee and advanced foot with ankle 
feature, prosthetic leg, and other parts. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says it is unclear if the enrollee is actually a K3 ambulator. 
 
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 items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the Ottobock Kenevo microprocessor knee (L5848, L5845, L5856, L5828) exceeds the patient's 
medical needs. The requested microprocessor knee has features such as intuitive use of a stationary indoor 
bicycle, adjustments from a smartphone with the Cockpit app, and convenience features of charging without 
removing the foam cover. The physician documentation does not reveal that the patient requires a 
microprocessor knee over a K3 mechanical knee. The requested Kenevo knee has deluxe features which are not 
medically necessary for the patient. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computerized knee and advanced foot with ankle feature, prosthetic leg, and other parts.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 77067 billed for date of service November 17, 2021. 
 
You asked the Plan to pay for procedure code 77067. You say that the records support the services billed. The 
Plan denied your request. The Plan says that 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 77067 is 1. The MAI value for this code is 2. However, the record only 
shows you billed one unit of this code. There is no evidence that you exceeded the MUE. Based on this 
information, we decided that Medicare rules for coverage of procedure code 77067 have been met. Therefore, 
we decided that the Plan has to pay for procedure code 77067 billed for date of service November 17, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the records provided support the need 
for the requested procedure. The Plan denied your request. The Plan says there is not enough medical evidence 
that shows this requested procedure is safe and as effective as other standard treatment options. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental, and more research is needed. 
 
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.