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

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
September 6, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 continuous glucose monitor (CGM) supplies rendered on 
September 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096). 
 
You asked the Plan to pre-approve the injection. You say that the injection is medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because your records show you do 
not have three diagnostic tests of sacroiliitis, and, because the request is requested at the same time as two facet 
medial branch blocks. 
 
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 injection. Our physician reviewer 
found the records do not demonstrate three diagnostic tests of sacroiliitis, and this request is being made at the 
same time as the request for two facet medial branch blocks. The review has determined that the medical 
records provided do not meet the requirements listed in the LCD for Medicare 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance 
(fluoroscopy or CT) including arthrography when performed (27096).
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 member meets the criteria for an IRF admission. 
The Plan denied your request. The Plan says the criteria for an IRF admission has 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 the complexity of the members nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The member continues to have a need for skilled therapy; however, the member does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation 
therapy program. There is not a reasonable expectation that this individual will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
The member can receive further services at a lower level of care. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service June 10, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. The Plan denied your request. The Plan says code 99153 
is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
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. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service June 10, 2022, billed with 
code 99153.
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 does not 
meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, rehabilitation, and medical needs do not 
require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on August 5, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this item is 
not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on August 
5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99496) provided on September 28, 2022, 
by an out-of-network (OON) provider. 
 
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 out-of-network services were not emergent or pre-authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for physician services (99496) provided on September 28, 2022, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a disposable drug delivery system (A4305) provided from 
February 14, 2022, to February 20, 2022. 
 
You asked the Plan to pay for a disposable drug delivery system. The Plan denied your request. The Plan says 
disposable drug delivery systems, including elastomeric infusion pumps (A4305) are non-covered devices 
because they do not meet the Medicare definition of durable medical equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a disposable drug delivery system have not been met. Therefore, we decided that the Plan does not 
have to pay for a disposable drug delivery system (A4305) provided from February 14, 2022, to February 20, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service September 2, 2021. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that these services 
were reported correctly. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. 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 CPT code(s) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic interventions that focus on cognitive function 
(e.g., attention, memory, reasoning, executive function, problem solving and/or pragmatic functioning) and 
compensatory strategies to manage the performance of an activity (codes 97129, 97130) provided on  
February 4, 2022.  
You asked the Plan to pay for the therapy services. The Plan denied your request. The Plan says the therapy 
services are experimental/investigational. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that based on the medical records provided there is no documentation 
that the requested therapy is generally accepted as specific and effective therapy for the enrollees condition. 
There is no documentation that the unique skills of a professional therapist are required to safely and 
effectively provide treatment, that the services can be safely and effectively performed only by a therapist or 
under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and 
judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the 
enrollees current condition or to prevent or slow further deterioration. The provided medical records do not 
document that the speech therapy services that focus on cognitive function have been shown in controlled 
studies to result in long term health benefits in patients with cognitive decline and confusion/memory 
difficulties. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pay for therapeutic interventions that focus on cognitive function (e.g., attention, memory, 
reasoning, executive function, problem solving and/or pragmatic functioning) and compensatory strategies to 
manage the performance of an activity (codes 97129, 97130) provided on February 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (procedure code 99220) rendered on 
April 17, 2021. 
 
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 the documents do not support this level of care. 
 
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 99220 is "Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit." 
 
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 records did not support a 
comprehensive history medical decision making of high complexity. 
 
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 initial observation care (procedure code 99220) rendered on April 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept basivertebral nerve ablation. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this treatment would be beneficial. 
The Plan denied your request. The Plan says this service remains experimental at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept basivertebral nerve ablation.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided from August 1, 2022, to October 31, 
2022, by an out-of-network provider. 
 
You asked the Plan to pay for the office visits. You say that you were unaware that this provider was not in 
network with you Plan as the Plan has paid them in the past. The Plan denied your request. The Plan says 
services from non-network providers are not covered unless Emergent or Urgent Care. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for office visits provided from August 1, 2022, to October 31, 2022, 
by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic analysis testing (81317, 81292, 81298, 81295, 
81300, 81297, 81319, 81294) provided on December 15, 2021. 
 
You asked the Plan to pay for the genetic analysis testing. The Plan denied your request. The Plan says this 
panel should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This testing was not billed with a single panel code as required. 
Based on this information, we decided that Medicare rules for coverage of the genetic analysis testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic analysis testing (81317, 
81292, 81298, 81295, 81300, 81297, 81319, 81294) provided on December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service October 13, 
2021. 
 
You asked the Plan to pay for procedure code 88341. You say that this service was reported correctly. The Plan 
denied your request. The Plan says payment for code 88341 is bundled into payment for code 88360. 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 88341 
is a column II code to column I code 88360. 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 88341 billed for date of service October 13, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete x-ray of foot, minimum of 3 views (73630) 
provided on November 04, 2022. 
 
You asked the Plan to pay for an x-ray. You say that the member had multiple exams done on this date of 
service. 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 November 25, 2022. 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 an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a complete x-ray of foot, minimum of 3 views (73630) provided 
on November 04, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal PCR (polymerase chain reaction) panel provided 
on May 6, 2022. 
 
You asked the Plan to pay for the fungal PCR panel. You say that this testing was medically necessary and 
appropriate. The Plan denied your request. The Plan says this panel is considered experimental/investigational 
and 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 pay for the fungal PCR panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee presented with toenail fungal infection and a fungal PCR panel was 
provided on May 6, 2022. Potassium hydroxide (KOH) testing or culture is the standard of care for testing for this clinical situation, and in most cases, no testing at all is required as it is typically treated empirically based 
on examination findings. There was no clinical documentation describing a special circumstance or risk or need 
to know a specific fungal organism to treat empirically. Therefore, without sufficient support made for this 
request, the PCR fungal panel will be considered 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 fungal PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the fungal PCR (polymerase chain reaction) panel provided on May 6, 2022.