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

 
We decided that the Plan does not have to pay for the neuromuscular junction testing (95937) and continuous 
intraoperative neurophysiology monitoring (G0453) provided on July 8, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the coverage guidelines have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that neuromuscular junction testing by repetitive 
stimulation may be reasonable and necessary to diagnose patients with fatigable weakness who are being 
evaluated for possible disease of the neuromuscular junction. 
 
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 the physician services. Our reviewer says 
that the physician services are not medically necessary. Our physician reviewer found the enrollee did not 
undergo neuromuscular junction testing (95937) as defined in the Local Coverage Determination (LCD). The 
train of four testing done was not consistent with neuromuscular junction testing as defined by the procedure 
code. Rather this code is considered to be inherent to any form of electromyography (EMG) testing. Therefore, 
the reviewer found that procedure code 95937 is not supported. The reviewer found that the use of 
intraoperative neurophysiology monitoring (IONM) in this type of surgery was not reflective of current 
standards of care. This surgery is not generally performed using IONM. In as much it does not reflect standards 
of care or practice and therefore 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 the physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for the neuromuscular junction testing (95937) and continuous intraoperative 
neurophysiology monitoring (G0453) provided on July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom-fabricated seat cushion (E2609, E2617). 
 
You asked the Plan to pre-approve the cushion. You say that this is medically necessary. The Plan denied your 
request. The Plan says a well-chosen pre-made seat cushion should be tried first. 
 
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 cushion. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the physical therapy evaluation states that the patient's seating and positioning needs can be met with 
a prefabricated seat and back. The requested custom-fabricated seat cushion (E2609, E2617) criteria have not 
been met.  
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 cushion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom-fabricated seat cushion (E2609, E2617).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department services provided on August 27, 
2022, billed with codes 74176, 93005, 96361, 96366, 96367, 96374, 96375, A4556, A4649, S0030, and A4208. 
 
You asked the Plan to pay for the services as billed. You say that this claim should be reimbursed at a higher 
rate to cover the expenses of providing the care. The Plan denied your request. The Plan says these codes 
cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
Medicare rules section of this decision explains the various coding rules applicable to this case. 
 
The records indicate that the services described by codes 74176, 93005, 96361, 96366, 96367, 96374, and 
96375 were provided to the enrollee while an inpatient or outpatient. Per the Physician Fee Schedule, there is a 
Professional/Technical indicator of 1 for CPT code(s) these codes. This means there is both a professional and 
technical component for the CPT code(s). In this case, an appropriate modifier to indicate the professional 
component has not been billed with these codes. 
 
CPT code S0030 has a status indicator of B on the Physician Fee Schedule. This means that procedure code is 
bundled and not separately payable. Codes A4556 and A4649 have a status indicator of P on the Physician Fee 
Schedule. Since they were billed along with a physician service, they are also not separately payable. Lastly, 
code A4208 does not have an approved allowed amount on the Physician Fee Schedule, so no payment can be 
made for this code. 
 
Based on this information, we decided that Medicare rules for coverage of procedure code the services as billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department 
services provided on August 27, 2022, billed with codes 74176, 93005, 96361, 96366, 96367, 96374, 96375, 
A4556, A4649, S0030, and A4208.
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 you are requesting reconsideration on the 
enrollee's behalf for an LTACH admission. The Plan denied your request. The Plan says the guidelines for 
admission to an LTACH have 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 the enrollee appears to be unstable and requires additional acute care services that can 
safely be provided at the current facility until more stable and appropriate for transfer. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer 
to the LTACH would not be clinically advantageous at this time and completion of treatment at the current 
facility is recommended. 
 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from November 4, 
2021, to November 6, 2021, as billed.   
 
You asked the Plan to pay for impatient services as billed. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the inpatient services as billed have 
been met. The provider has not included medical records for the hospital stay to support the services as billed. 
Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from 
November 4, 2021, to November 6, 2021, as billed.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee has cancer, and a scan has shown her bones 
are beginning to become weak. You say that the requested drug will be more effective for the enrollee. The 
Plan denied your request. The Plan says that the enrollee does not have a history of failure, contraindication, or 
intolerance to the formulary alternatives. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the enrollee is noted to have osteopenia 
while taking a nonsteroidal aromatase inhibitor.  A request has been made for Prolia to treat the osteopenia and 
prophylaxis against osteoporosis.  The Plan requires that zoledronic acid or pamidronate be used/tried.  These 
drugs are not indicated for osteopenia while taking an aromatase inhibitor.  As such, the step therapy 
requirement is medically inappropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent transportation mileage (A0100, 
A0425). 
 
You asked the Plan to pre-approve additional mileage. You say that you disagree with the denial. The Plan 
denied your request. The Plan says you are requesting additional mileage and your benefit only allows 75 
miles. The Plan also says you have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 12 one-way trips and each one-way trip must not exceed 75 miles of driving 
distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 75 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional non-emergent 
transportation mileage (A0100, A0425).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment methadone (G2067) provided on October 
24, 2022. 
 
You asked the Plan to pay for the services. You say that the provider is Substance Abuse and Mental Health 
Services Administration (SAMHSA) certified. The Plan denied your request. The Plan says that payment is not 
allowed for this claim because it does not meet the opioid treatment program criteria for payment. The Plan 
states per Centers for Medicare & Medicaid Services (CMS) that the Plan can only pay opioid treatment 
program claims for SAMHSA certified provider. 
 
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 services have been met. The claim was billed by the rendering 
provider of an OPT facility. The rules say that Medicare Part B coverage is available for outpatient Opioid 
Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), and Free-
Standing Opioid Treatment Program facilities. The rules say that only an entity enrolled with Medicare as an 
OTP can bill these codes. The facility is SAMHSA certified. Therefore, we decided that the Plan has to pay for 
medication assisted treatment methadone (G2067) provided on October 24, 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 72148 billed for date of service October 18, 
2022. 
 
You asked the Plan to pay for procedure code 72148. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 72148 is bundled into payment for code 72158. 
 
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 72148 
is a column II code to column I code 72158 with a modifier indicator of 0. The column II code is therefore not payable. 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 72148 billed for date of service October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 13 units of procedure code A4224 provided to the enrollee 
from July 13, 2022, to October 10, 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 Healthcare Common Procedure Coding System (HCPCS) code A4224-NU-KX (13 unit) remains 
not supported, as the records do not support the number of units billed for this service. 
 
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 A4224 is "Supplies for maintenance of insulin infusion 
catheter, per week." 
 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 patient did receive the 
diabetes supplies in the amount of 3 boxes of 30 each for a 90-day supply, However Medical records only 
indicated that the patient may use up to 3 per week. The records do not support the use of 13 units per week 
with A4224. 
 
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 13 units of procedure code A4224 provided to the enrollee from July 13, 2022, to October 10, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve thermal RFA services. You say that the request is urgent, and that the 
clinical documentation provided supports the need for RFA. The Plan denied your request. The Plan says the 
requested injection services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA services are covered for certain indications and 
when 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 thermal RFA services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the records provided do not 
demonstrate that 80% pain relief was achieved from both sets of blocks. Our physician reviewer found that the 
requested RFA services are 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 thermal RFA services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal radiofrequency ablation (RFA) services.
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. The Plan denied your request. The Plan says the enrollee's current 
level of function does not require an intensive, complex, multidisciplinary approach to daily therapy. 
 
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 clinical documentation does not specify complex functional impairments and 
documentation shows the enrollee is medically stable at home (with home health nursing).  
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: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for one unit of code 77002. We decided that the Plan does not have to pay 
for the second unit of 77002.  
 
You asked the Plan to pay for the medical services provided on April 18, 2022, billed with two units of code 
77002. You say that this is coded correctly and should be paid in full. The Plan says that the code 77002 only 
allows one unit per day and has a bilateral indicator of 0. This means that no payment can be made for the 
services as billed. 
 
 We decided that the Plan has to pay for one unit of code 77002.  
 
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, CPT code 77002 has a bilateral indicator of 0 in the Physician Fee Schedule. This means that if the 
code is reported with modifier -50 or modifiers -RT and -LT, the payment is based on the fee schedule amount 
for a single code, unless the total charge for both units is lower. 
 
Based on this information, we find that the rule support that payment should be made at the fee schedule 
amount for one unit of this code. Therefore, we decided that the Plan has to pay for one unit of code 77002.  
 
We also decided that the Plan does not have to pay for the second unit of 77002. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
As noted in the previous section, only one unit can be paid of code 77002. Therefore, we decided that the Plan 
does not have to pay for the second unit of 77002. 
 
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 71101 billed for date of service September 6, 
2022. 
 
You asked the Plan to pay for procedure code 71101. You say that the CPT code 71111 was billed but voided. 
The Plan denied your request. The Plan says payment for code 71101 is bundled into payment for code 71111. 
 
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 71101 
is a column II code to column I code 71111 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 71101 billed for date of service September 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and segmental 
pneumatic appliance (E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliance to be provided 
by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says 
there are in-network providers that are able to provide these services. Therefore, coverage criteria have not 
been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and segmental pneumatic appliance (E0667) to be provided by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira. 
 
You asked the Plan to pre-approve Humira. You say that the medication is necessary. The Plan denied your 
request. The Plan says your plan does not have a Medicare Part D benefit, or a separate pharmacy benefit 
managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Humira.  
 
Benefits for Humira may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.