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

 
We decided that the Plan does not have to pre-approve an expandable controller and related accessories 
(E2311, E2377, E2313). 
 
You asked the Plan to pre-approve an expandable controller and related accessories. You say that this item is 
medically necessary for the enrollee's operation of the power wheelchair. The Plan denied your request. The 
Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the requested expandable controller is subject to the 
criteria listed 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 an expandable controller and related 
accessories. Our reviewer says that the requested expandable controller and accessories are not medically 
necessary. Our physician reviewer found the enrollee has adequate upper body range of motion and strength to 
manage standard switches for control of multiple power drives. The requested expandable controller would 
exceed the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller and related accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller and related accessories (E2311, 
E2377, E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve heart catheterization and ventriculography (93458).

You asked the Plan to pre-approve the physician service. You say that the enrollee needs this service. The Plan denied your request. The Plan says the requested service 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 pre-approve the physician service. Our reviewer says that the requested heart catheterization and ventriculography is not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation indicates the enrollee had a negative radionuclide stress test in July 2022. The reviewer found that the guidelines do not support a need for cardiac catheterization in this setting. Therefore, the reviewer found that cardiac catheterization is not medically appropriate and necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physician service have not been met. Therefore, we decided that the Plan does not have to pre-approve heart catheterization and ventriculography (93458).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit for an established patient (99215) billed for 
date of service March 9, 2022. 
 
You asked the Plan to pay for an office visit for an established patient. You say that the services at issue were 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 99215 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of 
total time is spent on the date of the encounter." 
 
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 an office visit for an established patient. Our reviewer says 
that the code at issue does not meet criteria for payment. Our reviewer found that per the medical records, the 
office visit on the date of service at issue was a new-patient visit. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office visit for an established patient have not been met. Therefore, we 
decided that the Plan does not have to pay for an office visit for an established patient (99215) billed for date of 
service March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an upright walker.

You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your request. The Plan says that this is considered experimental and investigational.

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 walker. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the therapist has determined that the enrollee requires the walker to start the transition to ambulatory status. A walker is a standard of care device used to assist enrollee's during gait training and when transitioning in ambulation status.

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 walker have been met. Therefore, we decided that the Plan has to pre-approve an upright walker. 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and C1821).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion interspinous device at L2/L3, in this case, 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and C1821).
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 SNF care is medically necessary. The Plan denied your request. The Plan says that the coverage criteria has 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 the requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not have documented skilled nursing or therapy needs.

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 cardiovascular disease screening provided on March 23, 
2021. 
 
You asked the Plan to pay for the cardiovascular disease screening. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan follows Medicare rules. Cardiovascular risk assessment panels are only covered for certain 
indications. 
 
While cardiovascular risk assessment panels are covered for certain indications, the file does not support that 
the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular disease screening provided on March 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for code 95907-26 billed for date of service May 26, 2021.

You asked the Plan to pay for code 95907-26. You say that this service was billed correctly and should be paid. The Plan denied your request. The Plan says code 95907-26 is not supported in the medical records. The technical report did not include documentation of nerve conduction studies for 1-2 studies, therefore, this code cannot be verified.

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 95907-26 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 code 95907-26. Our reviewer says that code 95907-26 is not supported in the medical record. Our reviewer found the procedure report does not include documentation to support nerve conduction measuring amplitude, latency, and conduction velocity. (Per NCCI Policy, "Electrodes are placed directly over the nerve, in sensory conduction testing, or over the motor point of a specific muscle in motor conduction testing.  Electrical stimulation is applied, latency, amplitude, and conduction velocity are measured". Procedure report documents "95907 - Nerve Conduction Studies; 1-2 Studies; Results: Nerves were directly stimulated during lobe removal in order to map out the nerve.  Positive CMAP responses from the left and right Vocalis muscles were seen pre and post resection.  Times of each recorded response can be noted with the system file. SISA. RIRA".

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 95907-26 have not been met. Therefore, we decided that the Plan does not have to pay for code 95907-26 billed for date of service May 26, 2021.
Appeal type: Other
Decision: Unfavorable

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

We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen (CPT code 83789-59) provided on July 7, 2022.

You asked the Plan to pay for the service. You say that the claim has been underpaid. The Plan denied your request. The Plan says the records do not support testing of a non-drug analyte as indicated in the code description of the code billed. The Plan states that modifier 59 billed with 83789 is not supported in the documentation received, as the records do not support a separate and distinct lab service from the other performed/billed service.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  

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 service. Our physician reviewer found the documentation submitted was reviewed and does not meet criteria. Medical record includes documentation of a urine drug screen with specimen validity testing. In this case, specimen validity testing is included in the primary drug testing procedure and would not be reported separately. In this case, modifier -59 cannot be verified.

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 service have not been met. Therefore, we decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen (CPT code 83789-59) provided on July 7, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the occupational therapy to be provided by an out-of-network provider.

You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The Plan denied your request. The Plan says there is an in-network provider that can perform the services you need.

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 the occupational therapy to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair with power tilt and recline (K0856, E2361, E1028, E1002, E2620, E0955, E1012, E0956, E2311, E2603).

You asked the Plan to pre-approve a power wheelchair and accessories. You say that the documentation provided for the wheelchair and accessories are medically necessary to meet the enrollee's current needs. The Plan denied your request. The Plan says the enrollee does not have a medical need for single power options included with a power wheelchair. The electronic connection cannot be covered as it is not medically necessary to control the three requested power options through the joystick (drive interface). The enrollee does not meet criteria for tilt feature and therefore does not meet for the base code wheelchair with single power options.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 



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 power wheelchair and accessories. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has ataxia and has trouble with falling. She becomes easily short of breath and is struggling to complete ADLs in the home independently. She has elbow flexion and extension. The enrollee is not at high risk for skin breakdown, does not use intermittent catheterization and does not have spasticity.

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 power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair with power tilt and recline (K0856, E2361, E1028, E1002, E2620, E0955, E1012, E0956, E2311, E2603).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628).

You asked the Plan to pre-approve the intracept procedure. You say that the service is necessary. The Plan denied your request. The Plan says your request is not medically necessary because there is little evidence in the medical literature to suggest that this is an appropriate procedure for your back pain.

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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept proedure 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 the intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the facet joint injections (64493 and 64494).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records show they do not have any documented response to the first diagnostic facet block.

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 services. Our physician reviewer found there is no documentation that the second medial branch block injection at issue in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee. Provided records do not document any response to the first medial branch injection from October 24, 2022, as required by the LCD L38765. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the facet joint injections (64493 and 64494).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 63057, 63012-59,76000-59, 22610-59, 22216, and 
20650-59 
 
You asked the Plan to pay for codes 63057, 63012-59,76000-59, 22610-59, 22216, and 20650-59. You say that 
these codes are supported in the records. The Plan denied your request. The Plan says codes 63057, 63012-59,76000-59, and 22610-59 are inclusive to another billed code, and codes 22216 and 20650 are not 
documented. 
 
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 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 codes 63057, 63012-59,76000-59, 22610-59, 22216, and 
20650-59. Our reviewer says that these codes are not supported. Our reviewer found code 63057 is included in 
22633 and was not billed with a modifier to support separate payment. Codes 63012-59,76000-59, and 22610-
59 are not documented as separate services from the arthrodesis procedure. Codes 22216, osteotomy of spine, 
posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment, and 20650, 
insertion of wire or pin with application of skeletal traction, including removal, are not documented in the 
records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 63057, 63012-59,76000-59, 22610-59, 22216, and 20650-59 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 63057, 63012-59,76000-59, 
22610-59, 22216, and 20650-59
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computerized knee (CPT code(s): L5782 X 2, L5988 
X 2 and L5984 X 2). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the VASS suspension system exceeds the enrollee's medical need. The Plan states this 
cannot be covered, and the requested foot is miscoded and cannot be approved. 
 
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 items. Our physician reviewer 
found there is no change in the enrollee's physiology and the level of repair required does not exceed 60% of 
the cost of replacement. Much of the prosthesis are under warranty. The vacuum assist system does not have 
literature support or evidence-based support indicating it is 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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the computerized knee (CPT code(s): L5782 X 2, L5988 X 2 and L5984 X 2).