Persius/hicric huggingface dataset:
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 service. You say that the service is necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 service. 
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 for back pain. 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 pre-
approve the intracept procedure (CPT code 64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G2023-QW billed for date of service 
February 3, 2022. 
 
You asked the Plan to pay for procedure code G2023-QW. You say that this service was related to COVID-19 
testing and was billed appropriately. The Plan denied your request. The Plan says this service does not require 
the QW modifier and therefore was not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code does not require the QW modifier and use of this modifier with this code is not 
appropriate. Based on this information, we decided that Medicare rules for coverage of procedure code G2023-
QW have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G2023-
QW billed for date of service February 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology procedures of the spine and pelvis 
provided on May 31, 2022. 
 
You asked the Plan to pay for diagnostic radiology procedures of the spine and pelvis. You say that the x-ray 
services were not part of a settlement that happened twenty-years ago. The Plan denied your request. The Plan 
says the medical records cannot be accepted as proof that the services are not related to your open Workers 
Compensation case. The medical records do not prove that the services rendered were unrelated to your 
Workers Compensation case and could now be flaring up. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the file shows that 
medical records do not prove that the services rendered were unrelated to your Workers Compensation case. 
As the secondary insurer, the Plan cannot be held responsible for diagnostic radiology procedures of the spine 
and pelvis until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for diagnostic radiology procedures of the spine and pelvis provided on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extended respiratory pathogen panel provided on August 
4, 2022. 
 
You asked the Plan to pay for an extended respiratory pathogen panel. You say that this testing is supported as 
billed and was medically necessary. The Plan denied your request. The Plan says this panel does not meet 
criteria for medical necessity and was not billed in accordance with Medicare guidelines. 
 The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test is a single 
service with a single unit of service (UOS=1). A respiratory pathogen panel test must not be unbundled and 
billed as individual components regardless of the fact that the panel reports multiple individual pathogens 
and/or targets. Medicare rules also say that panels with more than five respiratory pathogens performed in a 
Part B outpatient setting are considered not medically reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the extended respiratory pathogen panel have not been met. Specifically, this panel was unbundled 
and billed as individual components, and this panel included more than five respiratory pathogens and was 
performed in an outpatient setting. Therefore, we decided that the Plan does not have to pay for an extended 
respiratory pathogen panel provided on August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the microfluid analysis provided on August 1, 2022. 
 
You asked the Plan to pay for the microfluid analysis. You say that you were billed for a procedure that your 
dentist did not include in the original claim that was submitted to the insurance. You say you are on a fixed income and needs to be reimbursed for the service. The Plan denied your request. The Plan says the service is 
not a Medicare-covered service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover this service. 
 
We looked at the file and the Plan's rules. Specifically, the service is not covered. Based on this information, 
we decided that the Plan's rules for coverage of the microfluid analysis have not been met. Therefore, we 
decided that the Plan does not have to pay for the microfluid analysis provided on August 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation 
states a specific laterality for the condition. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the 
medical record, assign the code for the unspecified side. 
 
We looked at the file and Medicare rules. As the medical record indicates a specific laterality, it is 
inappropriate to bill an unspecified diagnosis code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
services provided on September 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454) and a radiofrequency 
ablation procedure (64624). 
 
You asked the Plan to pre-approve a genicular nerve block and a radiofrequency ablation. You say that the 
requested services are a medical necessity for you. The Plan denied your request. The Plan says the requested 
services are experimental/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 a genicular nerve block and a 
radiofrequency ablation. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the role of genicular nerve blocks and of 
radiofrequency ablation is the subject of ongoing clinical trials. The requested services are considered 
experimental/investigational 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 a genicular nerve block and a radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block (64454) and a 
radiofrequency ablation procedure (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition solution (B4197). 
 
You asked the Plan to pay for the parenteral nutrition solution. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the submitted medical records don't include a patient 
receipt or proof of delivery of the supply on the billed date of service to indicate the patient is in receipt of the 
billed item. 
 
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 proof of delivery for the supplies provided in this case. The submitted 
medical records don't include a patient receipt or proof of delivery of the supply on the billed date of service to 
indicate the patient is in receipt of the billed item. 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 parenteral nutrition solution (B4197).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628 and 64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are medically necessary. 
The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered 
by Medicare due to insufficient evidence of efficacy. 
 
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 procedure is experimental for back pain. 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 (64628 and 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim should be covered. 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 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept) procedure (64628 x 2, 64629 x 2). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure fills a treatment gap for 
those that do not receive adequate relief from traditional conservative methods and do not have instability to 
indicate fusion is the appropriate treatment. The Plan denied your request. The Plan says the requested 
procedure 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is considered experimental for treatment of back pain. 
Therefore, the reviewer found that an Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept) procedure (64628 x 
2, 64629 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high strength, lightweight wheelchair (K0004) and 
elevating leg rests (K0195). 
 
You asked the Plan to pre-approve a high strength, lightweight wheelchair, and elevating leg rests. You say that 
the use of the requested wheelchair would greatly improve your quality of life due to your muscle weakness. 
You would be able to be mobile in your home, complete your activities of daily living and get back to a normal 
life. The Plan denied your request. The Plan says there is no specific explanation given why the heavy-duty 
version of the lightweight wheelchair was requested for you as the current standard lightweight manual 
wheelchair is meeting your needs in your home. The requested wheelchair is not demonstrated to be necessary 
based on observation of your actual use of a standard lightweight manual chair. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that you do not meet coverage criteria for coverage 
of the requested wheelchair. You do not show a need for this type of chair. Based on this information, we 
decided that Medicare rules for coverage of a high strength, lightweight wheelchair and elevating leg rests have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a high strength, lightweight 
wheelchair (K0004) and elevating leg rests (K0195).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4959), 
provided on June 11, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the item is medically necessary. 
The Plan denied your request. The Plan says The information provided with the appeal does not include any 
documentation of diffuse muscle atrophy where never supply to the muscle is intact, including brain, spinal 
cord, and peripheral nerves, or other non-neurological reasons for diffuse atrophy. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of Neuromuscular Electrical Stimulation 
(NMES) to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle 
is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse 
atrophy. Some examples would be casting or splinting of a limb, contracture due to scarring of soft tissue as in 
burn lesions, and hip replacement surgery (until orthotic training begins). (See 160.13 of the NCD Manual for an explanation of coverage of medically necessary supplies for the effective use of NMES.). 
 
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 electrical stimulator supplies. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found there is no 
documentation of diffuse muscle atrophy where never supply to the muscle is intact, including brain, spinal 
cord, and peripheral nerves, or other non-neurological reasons for diffuse atrophy. 
 
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 electrical stimulator supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4959), provided on 
June 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl (CPT code J0896). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of Reblozyl in the setting of myelodysplastic 
syndrome without ring sideroblasts have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 medication. Our physician reviewer 
found the clinical value and effectiveness of Reblozyl in the setting of myelodysplastic syndrome without ring 
sideroblasts have not been demonstrated in the literature. The review has determined that the documentation 
does not support that the Reblozyl is medically reasonable and necessary for the enrollee. The documentation 
does not support that the Reblozyl is safe and effective for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Reblozyl (CPT code J0896).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Trulicity injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Trulicity is on the self-administered drug list and is excluded from coverage under 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Trulicity injection.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service September 8, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99291 is bundled into payment for code 92950. 
 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 99291 
is a column II code to column I code 92950. 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 99291 billed for date of service September 8, 
2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for hospital services provided on March 5, 2021, at the original rate paid. 
 
You asked the Plan to pay for hospital services at the original rate paid. You say that the overpayment refund 
was requested over a year after this claim was paid. The Plan denied your request. The Plan says that this claim 
was overpaid. 
 
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. Specifically, the Plan has provided no argument/explanation for denial or to 
explain the overpayment in this case, nor has any evidence been provided to support any argument. Therefore, 
we decided that the Plan has to pay for hospital services provided on March 5, 2021, at the original rate paid.  
 
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 pay for the inpatient hospital services coded as 15100, 15101, 15004 
and 15002 provided January 25, 2022. 
 
You asked the Plan to pay for the hospital services. You say that please review the claim with the attached 
medical records and process the claim for payment. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 31, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services coded as 15100, 
15101, 15004 and 15002 provided January 25, 2022.