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

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that Intracept is medically necessary and supported by 
strong science. The Plan denied your request. The Plan says there are not enough studies to show this is safe 
and effective. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and 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 February 18, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal surgery (20930, 20936, 22551, 22552, 22845, 22853). 
 
You asked the Plan to pre-approve the spinal surgery. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the spinal surgery. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found provided documentation demonstrates subjective and objective deficits that are corroborated by 
imaging studies. Trial and failure of conservative treatment modalities have been documented. Therefore, the 
requested anterior cervical discectomy and fusion at C5-6 and C6-7 with allograft, in this case, is medically 
reasonable and 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 spinal surgery have been met. Therefore, we decided that the Plan has to 
pre-approve a spinal surgery (20930, 20936, 22551, 22552, 22845, 22853).  
 
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 99024 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 99024. You say that you have provided medical records showing 
that this service should be paid. The Plan denied your request. The Plan says procedure code 99024 is 
considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99024 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99024 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99024 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99024 billed for date of service August 30, 2022.
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 a LTACH admission is the appropriate 
placement for the enrollee at this time. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) billed for date of service 
October 21, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says another definitive drug testing code has 
already been paid for this enrollee for this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that only one code from the G0480-G0483 code set 
group for definitive drug testing may be reported per date of service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Specifically, the documentation shows that another definitive drug 
testing code (G0480) has already been billed for this enrollee and date of service. This other drug testing code has already been paid. Therefore, we decided that the Plan does not have to pay for definitive drug testing 
(G0483) billed for date of service October 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit provided on October 4, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, this service was billed with 
diagnosis code T44.7X5A (Adverse effect of beta-adrenoreceptor antagonists, initial encounter). This diagnosis 
code is a "code first" diagnosis and is not acceptable as a primary diagnosis as billed. The claim is not payable 
as billed. Based on this information, we decided that Medicare rules for coverage of the emergency department 
visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department 
visit provided on October 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to an LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-
patient acute care and does not require transfer to an LTACH. 
 
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 that the enrollee appears to be improving with current treatment and is approaching 
baseline and should only require short-term additional acute care services that can safely be provided at the 
current facility until more stable and appropriate for a lower level of care. The enrollee does not require 
services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not 
medically necessary at this time as it would not be clinically advantageous. 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing (87635) provided on August 31, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for COVID-19 testing. You say that this test was required by the airline for you to 
return to the country. The Plan denied your request. The Plan says this test was provided by an out-of-network 
provider and was not medically necessary as it was provided for the purpose of travel rather than for the 
treatment or diagnosis of an illness or injury. 
 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. Medicare rules also say that items and services that are not 
medically necessary are not covered. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. In addition, the test at issue was provided for travel purposes only and was not performed 
for the treatment or diagnosis of an illness or injury for which you were showing symptoms or had known 
exposure. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for COVID-19 testing (87635) provided on August 31, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a continued SNF stay. The Plan denied your request. The Plan says based on the information provided, medical 
necessity for a continued SNF stay is not 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 2, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided August 14, 2022. 
 
You asked the Plan to pay for the TENS device. You say that note that according to the enrollee's prescription, 
the prescribing physician recommends an extended lifetime use of equipment as they are diagnosed with 
chronic pain and compromised mobility without the option for surgical correction. The Plan denied your 
request. The Plan says there is no evidence to support the ordering provider is ordered the service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the ordering provider 
office and confirmed that there is no order on file for the electrical stimulator. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) device (E0730) provided 
August 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0279) provided on June 23, 2022. 
 
You asked the Plan to pay for code G0279. The Plan denied your request. The Plan says the add-on code was 
not billed with an appropriate primary code. 
 
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 G0279 
is an add-on code and has not been billed with an appropriate primary procedure code. 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 (G0279) provided on June 23, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice on the date in question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the services provided on July 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service October 3, 
2022. 
 
You asked the Plan to pay for procedure code 76770. The Plan denied your request. The Plan says payment for 
code 76770 is bundled into payment for code 93976. 
 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 76770 
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 procedure code 76770 billed for date of service October 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care following surgery or 
could lose their vision permanently. You say the enrollee has dementia and will need 24 hour care. The Plan 
denied your request. The Plan says based on Medicare guidelines, the SNF service you are requesting do not 
meet the requirements for approval. 
 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 have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs are custodial and can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare guidelines for care in an LTACH. 
 
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 improving with current treatment but not yet stable for 
transfer. There are no services available 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: 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 hospital staff recommended rehab and skilled 
nursing care. The Plan denied your request. The Plan says the SNF services you are requesting do not meet the 
requirements for approval. 
 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 have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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.