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

 
We decided that the Plan does not have to pre-approve a repeat medial branch block (MBB). 
 
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 repeat MBBs are covered when specific criteria 
are met. 
 
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 enrollee underwent bilateral lumbar 
medial branch blocks (MBBs) in August of 2022 that provided 70 percent pain relief. This initial injection did 
not result in 80 percent pain relief as required by the Medicare criteria. The requested repeat MBB is therefore 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat medial branch block (MBB).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have a fractured femur, and your doctor is 
recommending IRF services to help you gain movement. The Plan denied your request. The Plan says the 
requested IRF services are not medically necessary.  
 
 
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. You may have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that you would meet criteria for admission to an acute IRF.  There is no indication you would 
require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, and require the 
supervision of a physician with at least 3 visits weekly to regain or maintain your functional status. Our review 
found you can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show failed treatment with continuous positive airway pressure 
(CPAP) or bilateral positive airway pressure (BiPAP). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that this patient 
has been hospitalized twice in the last several months, and arterial blood gas (ABG) was consistent with 
chronic hypercarbic respiratory failure. The hospital records mention possible obesity hypoventilation 
syndrome and obstructive sleep apnea. There is no mention in the hospital records of COPD as a diagnosis. There are no pulmonary function tests. The patient is severely obese. There is no diagnosis of 
thoracic restrictive disease or neuromuscular disease. There is no ABG, done while stable, to confirm chronic 
CO2 retention. If the patient does have chronic CO2 retention, may benefit from continuous positive airway 
pressure (CPAP) or bilevel positive airway pressure (BiPAP) during sleep. Medicare does not cover a home 
ventilator for the treatment of obesity hypoventilation syndrome, or when used at settings that can be provided 
with BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the facet joint injections. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the patient must have two (2) medically reasonable 
and necessary diagnostic facet joint procedures with each one providing a consistent minimum of 80% relief of 
primary (index) pain (with the duration of relief being consistent with the agent used) for therapeutic facet joint procedures to be considered 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 facet joint injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the patient did not have two 
diagnostic blocks with a greater than 80% pain relief. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet joint injections (64493, 64494).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75710 billed for October 13, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 75710 is 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 75710 is angiography, extremity, unilateral, radiological 
supervision and interpretation. 
 
We find that CPT code 75710 is not supported in the medical record. Specifically, the file shows that routine 
dialysis access related angiography was performed and there is a more appropriate code for the services. Based 
on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 75710 billed for October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical nerve stimulator and supplies provided on July 
27, 2022. 
 
You asked the Plan to pay for the device and supplies. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS is not reasonable and necessary for the 
treatment of chronic low back pain  
 
We looked at the file and Medicare rules. The records show that the TENS device and supplies in this case 
were provided for chronic low pain. A TENS device and supplies are not covered for treatment of chronic low 
back pain. Based on this information, we decided that Medicare rules for coverage of the device and supplies 
have not been met. Therefore, we decided that the Plan does not have to pay for the electrical nerve stimulator 
and supplies provided on July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you do not believe you will be able to walk correctly 
without the IRF services. The Plan denied your request. The Plan says the requested IRF admission is not 
medically necessary. 
 
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 you do not require intensive rehabilitation to recover from knee arthroplasty. Our 
reviewer also found that you do not have complex needs nor do you require frequent physiatry oversight. 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge day management services billed with code 
99239 for November 15, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a physician may not bill the hospital observation 
discharge management code for the care provided while the patient received hospital outpatient observation 
services on the date of admission to inpatient status.  
 
We looked at the file and Medicare rules. The file shows that procedure code 99239 was billed on the same day 
the enrollee received outpatient observation services on the date of admission to inpatient status. Therefore, we 
decided that the Plan does not have to pay for the discharge day management services billed with code 99239 
for November 15, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered on September 
27, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
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, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services rendered on 
September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oncology germline panel billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 81407, 
81408, and 81479 provided on August 26, 2022. 
 
You asked the Plan to pay for the comprehensive oncology germline panel. You say that this claim should be 
paid. The Plan denied your request. The Plan says criteria for coverage are not met. Additionally, the panel 
should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the comprehensive oncology germline panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oncology germline panel billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 81407, 81408, and 81479 
provided on August 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blood pressure monitory (A4670). 
 
You asked the Plan to pre-approve a blood pressure monitor. You say that you would like to appeal this denial. 
The Plan denied your request. The Plan says the requested item is not covered by Medicare or the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a blood pressure monitory (A4670).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services related to end-stage renal disease (ESRD) provided on 
September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete bilateral non-invasive study of the upper/lower 
extremity arteries rendered on January 31, 2022. 
 
You asked the Plan to pay for the study. You say that this was medically necessary. The Plan denied your 
request. The Plan says this service is not Medicare benefits for the diagnoses listed on the claim or found in the 
clinical record. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the study. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the report of the ultrasound study on January 31, 2022, includes a description of the bilateral lower 
extremity arterial ultrasound findings. While there is mention in the heading of a bilateral ankle brachial index 
(ABI), no differential pressures of the upper and lower extremities are mentioned; nor is there mention of 
arterial findings in the upper extremities. Absent such documentation the charge for bilateral upper extremity 
arterial ultrasound is not supported by the submitted report. 
 
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 study have not been met. Therefore, we decided that the Plan does not have 
to pay for a complete bilateral non-invasive study of the upper/lower extremity arteries rendered on January 31, 
2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 76998-26. We decided that the Plan does not have to 
pay for procedure code 61518.  
 
You asked the Plan to pay for procedure codes 76998-26 and 61518 billed for March 11, 2022. You say that 
you disagree with the denial. The Plan says that procedure code 76998 is inclusive to code 61518 and code 
61518 is not separately payable. We decided that the Plan has to pay for procedure code 76698-26.  
 
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 states that code 76998-26 is not separately payable because it is 
inclusive to code 61518; however, there is no National Correct Coding Initiative edit for this code pair that 
states code 76998 is inclusive to code 61518. The Plan has not provided any documentation or binding 
Medicare rules to support that code 76998 is not payable as billed. Therefore, we decided that the Plan has to 
pay for procedure code 76998-26 billed for March 11, 2022.  
 
We also decided that the Plan does not have to pay for procedure code 61518. 
 
The Plan must follow Medicare rules. The rules say that follow-up services are included in the global surgical 
package. 
 
The file shows that procedure code 61518 was billed within 90 days and related to major surgical procedure 
code 61796 billed for March 8, 2022. Payment for code 61518 is included in the global surgical package for 
code 61796. Therefore, we decided that the Plan does not have to pay for procedure code 61518 billed for 
March 11, 2022. 
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (87798) provided on August 27, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that this code is 
included in codes 87801 and 87150. 
 
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 argues that code 87798 is included in codes 87801 and 87150. While 
this is true, the records provided do not show that codes 87801 and 87150 were billed on the date of service in 
question, which means that code 87798 is separately payable. Without supporting documentation, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the lab services (87798) 
provided on August 27, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services related to end-stage renal disease (ESRD) provided on August 
5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88104, 88112, 88305) provided on December 
13, 2021. 
 
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 when an enrollee is a registered inpatient of a 
hospital, then the appropriate place of service, regardless of where the face-to-face service occurs, is that of the 
appropriate inpatient POS code. 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, the records show that the enrollee was inpatient 
status from December 1, 2021, to December 30, 2021. However, this claim was not submitted with an inpatient 
POS code. Therefore, we decided that the Plan does not have to pay for lab services (88104, 88112, 88305) 
provided on December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88291, 88368, 88369, and 88377, billed for 
date of service July 12, 2022. 
 
You asked the Plan to pay for procedure code 88291, 88368, 88369, and 88377. The Plan denied your request. 
The Plan says payment for codes 88291, 88368, 88369, and 88377, is bundled into payment for code 81279.  
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 codes 
88291, 88368, 88369, and 88377, are column II codes to column I code 81279. 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 codes 88291, 88368, 
88369, and 88377, billed for date of service July 12, 2022.