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

 
We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer 
(Vertiflex) procedure (22869). 
 
You asked the Plan to pre-approve Vertiflex procedure. You say that this procedure is considered safe and 
effective. The Plan denied your request. The Plan says the requested procedure is considered experimental and 
investigational. 
 
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 Vertiflex procedure. Our reviewer says 
that the requested Vertiflex procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested Vertiflex procedure is considered experimental and investigational. The 
reviewer found that additional research is needed to show safety and efficacy. Therefore, the reviewer found 
that the requested procedure is not medically reasonable or 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a posterior interspinous decompression spacer (Vertiflex) procedure (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says you do not meet the criteria for an IRF level of 
care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure (HF) system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMs device was approved 
by the Food and Drug Administration (FDA) in 2014. Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
patient management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure (HF) system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 17, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says medical records 
were not submitted. 
 
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. Medicare rules also say that the physician must clearly document, in the 
medical record, his or her intent that the testing be performed. 
 
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 lab services have been met. The 
submitted documentation only contains a test requisition form. Medical records from the ordering provider 
were not submitted. Therefore, we decided that the Plan does not have to pay for the lab services provided on 
November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental anesthesia. 
 
You asked the Plan to pre-approve dental anesthesia. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this service is not covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental anesthesia.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the necessary services on an inpatient basis, in a skilled 
nursing facility setting. The enrollee does not have daily skilled nursing needs. The enrollee's functional 
impairment preceded the hospital stay. As she had major functional loss prior to a hospital stay, there was no 
significant change during the hospital stay. Criteria for acute skilled therapy is not 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will require another 2 -3 
weeks to continue complex medical would care, physical and occupational therapy. The Plan denied your 
request. The Plan says an LTACH admission is not medically necessary, and the enrollee's needs can be met in 
the current hospital setting. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code(s) 88305. 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) 88305. 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) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service July 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20680 and 11960 billed for date of service 
May 31, 2022. 
 
You asked the Plan to pay for procedure codes 20680 and 11960. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 20680 is 
bundled into payment for code 21627. Additionally, procedure code 11960 has an assistant at surgery indicator 
of 1 and is not covered. 
 
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 20680 
is a column II code to column I code 21627 with a modifier indicator of 0. The column II code is therefore not 
payable. 
 
Additionally, Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon 
services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology 
(CPT) code 11960. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. 
This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be 
paid.  
 
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 codes 20680 and 11960 billed for date of service May 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transports provided on February 18, 2022 to April 
18, 2022. 
 
You asked the Plan to pay for the ambulance transports. You say that the  records provided support the need for 
the ambulance transports. The Plan denied your request. The Plan says the ambulance transports were not 
medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the ambulance transports. Our reviewer says 
that the ambulance transport services were not medically necessary. Our physician reviewer found the enrollee 
was transported via ambulance from their residence to the hospital for dialysis. The enrollee was reported to a 
have been weak and needed assistance with sitting so stretcher was used. Vitals were stable, physical 
examination and mental status was normal and at baseline for patient.  He was transported without complication or need for any treatment during the trips. The documentation does 
not support that other means of transport (such as a stretcher van) were contraindicated for the enrollee. The 
documentation does not show that the enrollee needed the expertise, services and life-sustaining equipment that 
only fully equipped ambulance can provide for safe transport. The documentation does not support that the 
ambulance transports were medically reasonable and necessary for the enrollee based on the provided 
documentation. 
 
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 ambulance transports have not been met. Therefore, we decided that the 
Plan does not have to pay for ambulance transports provided on February 18, 2022 to April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that you disagree with the denial for 
compression stockings. The Plan denied your request. The Plan says that the requested compression stockings 
are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee's progress can only occur 
with further medically necessary skilled physical therapy which is safe and effective restorative care for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for continued 
physical therapy. 
 
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 pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has chronic back pain but had improved function to a 
good range. The enrollee has an effective treatment model and may continue at home with a home exercise 
program. Continued input from a skilled therapist 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 16 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service January 17, 2022. 
 
You asked the Plan to pay for code 99233. You say that you billed this service correctly. The Plan denied your 
request. The Plan says you billed with an incorrect POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill using the correct Place of 
Service (POS) code.  Services rendered in an inpatient hospital setting should be billed with POS code 21.  
Services rendered in an outpatient hospital setting should be billed with POS code 22.  In this case, you billed 
POS code 21, which indicates that the services were performed in an inpatient hospital setting.  However, 
billing records show that the patient has not an inpatient on this date of service, but instead was in observation 
care at the hospital.  Observation is an outpatient status, so the POS code should have been 22. Based on this 
information, we decided that Medicare rules for coverage of code 99233 have not been met. Therefore, we 
decided that the Plan does not have to pay for code 99233 billed for date of service January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a network benefits exception for an out-of-network 
neurological surgery consultation. 
 
You asked the Plan to pre-approve a network benefits exception for a neurological surgery consultation. You 
say that you have seen this doctor in the past. The Plan denied your request. The Plan says there are in-network 
providers available. 
 
Medicare rules say that Preferred Provider Organizations (PPOs) must furnish all services in-network and out-
of-network, but may charge higher cost-sharing for plan covered services obtained out-of-network. The 
contract with the Plan says that the cost-sharing for out-of-network services is higher unless a provider is not available in the network within a reasonable distance from the enrollees home or the services are emergency 
care, urgently needed services, or out-of-area dialysis. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve a benefit exception for this service. Therefore, we decided that the Plan does not have to 
pre-approve a network benefits exception for an out-of-network neurological surgery consultation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require interdisciplinary oversight, lab 
monitoring, and pain management. You say that services you need cannot be provided at a lower-level facility. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary, and your needs can 
be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, 88377, and 88381 
billed for date of service April 7, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, 88360, 88377, and 88381. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says these codes are 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 codes 88341, 88342, 88360, 
88377, and 88381. This means there is both a professional and technical component for the CPT codes. In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT codes 
88341, 88342, 88360, 88377, and 88381. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341, 88342, 88360, 88377, and 88381 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 88341, 88342, 88360, 88377, and 88381 billed for date 
of service April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345-GZ billed for date of service June 13, 
2022. 
 
You asked the Plan to pay for procedure code 81345-GZ. You say that this service was billed correctly and you 
have provided medical records showing the necessity of this service. The Plan denied your request. The Plan 
says payment for code 81345-GZ is bundled into payment for code 0089U. 
 
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 
81345-GZ is a column II code to column I code 0089U. This claim has not been billed with an appropriate 
modifier to bypass the edit. In fact, the only modifier billed with this code was the GZ modifier, which 
indicates that you are aware that this service is not medically necessary and not covered. 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 81345-GZ billed for date of service June 13, 2022.