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

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says there are providers in-network available to handle your 
medical 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 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 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99100) provided on August 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99100 is not separately payable. 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 the services 
(99100) provided on August 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep study. 
 
You asked the Plan to pre-approve a home sleep study. The Plan denied your request. The Plan says given the 
member is not readily suspected of having obstructive sleep apnea (OSA) and the use of another home sleep 
test would not meet Medicare requirements for coverage. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home sleep study. Our reviewer says 
that a home sleep study is not medically necessary. Our physician reviewer found that the enrollee is an  
81-year-old male with a history of insomnia, coronary artery disease (CAD), atrial fibrillation, asthma, Benign 
prostatic hyperplasia (BPH), neuropathy, depression, and alcohol use disorder. He reports waking up tired. 
There is no history of snoring or apnea. There is no specific clinical rational for a home sleep study. The 
enrollee has chronic insomnia and alcohol use disorder. The review has determined that the requested home 
sleep study does not meet the Medicare coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home sleep study have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home sleep study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker, folding, wheeled, adjustable or fixed height 
(E0143) and sales tax (S9999) provided on November 24, 2021. 
 
You asked the Plan to pay for a walker. You say that you have sent in appeal information twice and you were 
told that the wrong doctor's name was attached to the case. The Plan denied your request. The Plan says the 
requested DME supplier is not under contract with the Plan and is not certified with Medicare. The Plan also 
says that sales tax is never covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the DME supplier at issue is not enrolled in the 
Medicare program. Therefore, we decided that the Plan does not have to pay for a walker, folding, wheeled, 
adjustable or fixed height (E0143) and sales tax (S9999) provided on November 24, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on October 7, 
2020. 
 
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 the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until February 10, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the emergency room (ER) services rendered on October 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 14, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on December 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says there is a lack of evidence to support the requested 
procedure. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation indicates that the enrollee has chronic low back pain and lumbar 
spinal stenosis with neurogenic claudication. The Food and Drug Administration states that the Superion 
Interspinous Spacer is indicated to treat skeletally mature patients suffering from pain, numbness, and/or 
cramping in the legs (neurogenic intermittent claudication) secondary to a diagnosis of moderate lumbar spinal 
stenosis, with or without Grade 1 spondylolisthesis, confirmed by X-ray, MRI and/or CT evidence of thickened 
ligamentum flavum, narrowed lateral recess, and/or central canal narrowing. The Superion Interspinous 
Spacer is indicated for those patients with impaired physical function who experience relief in flexion from 
symptoms of leg/buttock/groin pain, with or without back pain, who have undergone at least 6 months of non-
operative treatment. The Superion Interspinous Spacer may be implanted at one or two adjacent lumbar levels 
in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. The Food and 
Drug Administration states that the requested procedure is contraindicated if the individual has a body mass 
index of greater than 40. The record indicates that the enrollee has multi-level degenerative disease. The record 
indicates that the enrollee has a body mass index of greater than 40. The elements of the coverage criteria are 
not satisfied. The requested service cannot be 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
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 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 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 18, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 93976. 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 the abdominal ultrasound (76705) provided on January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (25111) provided on October 12, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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, we have confirmed that code 25111 
is a column II code to column I code 64721. 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 the services (25111) provided on October 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is a medical necessity for you. The Plan 
denied your request. The Plan says medical necessity rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you have no identifiable skilled nursing 
service needs. You do have identifiable skilled therapy service needs; however, you do not require skilled 
nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 1, 2021. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these 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 the laboratory services rendered on October 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on December 23, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel 
you should have at the least an ambulance copayment and not be charged the full amount of the bill. You also 
say that the fire department came immediately but it took the ambulance 35 minutes to arrive. The Plan denied 
your request. The Plan says you received treatment, but no transport. The Plan also says that, per the records 
provided, you signed a refusal for transport/and or treatment, despite the ambulance advising it would be 
beneficial for you to be treated by the hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 23, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve a repeat lumbar epidural steroid injection.. You say that this is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat epidural steroid injection (ESI) when the 
first injection directly and significantly provided improvement of the condition being treated may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline for at least three months. 
 
We looked at the file and Medicare rules. In this case, the documentation confirms that three months have not 
passed since the first epidural steroid injection. Based on this information, we decided that Medicare rules for 
coverage of a repeat lumbar epidural steroid injection. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat lumbar epidural steroid injection.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing provided on December 15, 2021. 
 
You asked the Plan to pay for lab test. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says that the denial of payment for this testing is correct, because this provider is out-of-
network with the Plan and authorization was not obtained. 
 
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. The Plan did not submit a copy of the applicable Evidence of Coverage (EOC) 
for this enrollee and date of service. We requested this information, but it was not provided to us. Without this 
information, we cannot determine whether there is a contractual network lock-in rule that would apply to this 
testing. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or 
justified according to Medicare rules and the enrollees contract with the Plan. Therefore, we decided that the 
Plan has to pay for laboratory testing provided on December 15, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95955, 95885, 95907) provided on May 24, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
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 95955 is "Electroencephalogram (EEG) during 
nonintracranial surgery (eg, carotid surgery)". The CPT Code Manual definition of code 95885 is "Needle 
electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, 
amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure)". The 
CPT Code Manual definition of code 95907 is "Nerve conduction studies; 1-2 studies". 
 
 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 use of codes 95955, 
95885, and 95907, is not supported by the records provided. Our reviewer found that CPT 95955 is a "Special 
EEG Test". The technical report does not include documentation of an additional EEG performed. Any 
additional EEG testing would be inclusive to the neuromonitoring procedure code. For CPT 95885. This 
procedure is "done with nerve conduction studies", per CPT code description. The technical report does not 
include documentation of nerve conduction studies, and therefore this procedure cannot be verified. For CPT 
95907, the technical report does not include documentation of nerve conduction studies, and therefore cannot 
be verified as performed. 
 
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 the services (95955, 95885, 95907) provided on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet joint injections. 
 
You asked the Plan to pre-approve lumbar facet joint injections. The Plan denied your request. The Plan says 
facet joint injections-lumbar are not medically necessary and do not meet the Medicare LCD coverage criteria.  
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve lumbar facet joint injections. Our 
reviewer says that lumbar facet joint injections are not medically necessary. Our physician reviewer found that 
according to the coverage criteria, facet joint injections are indicated when there is absence of untreated 
radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst). In this 
case, the enrollee has radiculopathy. The review has determined that the requested lumbar facet injections are 
not medically necessary or reasonable and do not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar facet joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve lumbar facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on January 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (70450) provided on January 20, 2022.