Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a geniculate artery embolization procedure (37242, 
37243, 36247, 36248, 76937). 
 
You asked the Plan to pre-approve a geniculate artery embolization. You say that the requested services are a 
medical necessity for the enrollee. 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 geniculate artery embolization. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive, less invasive, conservative-care measures for the right knee. Additionally, there is 
limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective 
and/or safe treatment for the enrollee's pathology. While the studies are noted to be promising, further 
studies/research is needed to corroborate that geniculate artery embolization is as good as or better than 
standard treatments for knee osteoarthritis. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 geniculate artery embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a geniculate artery embolization procedure (37242, 37243, 36247, 
36248, 76937).
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 you are requesting a reconsideration for 
the denied LTACH admission. The Plan denied your request. The Plan says the member is receiving 
appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital (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 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 as it would not be clinically advantageous at 
this time. 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 procedure codes 87150, 87481, 87641, 87653, and 87798 
billed for date of service June 22, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, and 87798. The Plan denied your 
request. The Plan says payment for codes 87150, 87481, 87641, 87653, and 87798 is bundled.  
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 87150 
is a column II code to column I code 87500. We have also confirmed that codes 87481, 87641, 87653, and 
87798, are column II codes to column I code 87150. 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 87150, 87481, 87641, 87653, and 
87798 billed for date of service June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 14 sensor (CPT code A4239). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says the CGM is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our physician reviewer 
found you are not taking 3 shots of insulin a day, the records do not show how the doses are adjusted based on 
the blood glucose levels and the records do not show why a glucometer used two times a day does not suffice 
for your needs 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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the FreeStyle Libre 14 sensor (CPT code A4239).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the enrollee's ongoing skilled nursing and therapy needs can be met at a lower 
level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has a chronic deconditioned state and does not require intensive  rehabilitation or frequent physiatry oversight. The enrollee is functioning at a level routinely managed without 
an IRF admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA lab services provided on September 27, 2022. 
 
You asked the Plan to pay for the PrismRA lab services. You say that this claim should be reprocessed. The 
Plan denied your request. The Plan says there was no medical record documentation provided to prove that the 
services met coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that your lab must maintain and provide sufficient 
medical record documentation to show the medical necessity of the services provided.  In this case, you have 
provided no medical records except for your lab report to substantiate the medical necessity of these services.  
Further, the Plan attempted to get medical records from the ordering provider with no response.  As the lab 
submitting this claim for payment, it is your obligation to maintain and provide sufficient medical records to 
prove that coverage criteria are met. You have not done so in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PrismRA lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for the PrismRA lab services provided on September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service September 
17, 2021. 
 You asked the Plan to pay for procedure code 88342. You say that it was medically necessary to bill 5 units of 
CPT 88342. You billed a total of 5 units of 88342 and have received payment of 4 units. The Plan denied your 
request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88342 is 4. The MAI value for this code is 3. You billed 5 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88342 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88342 billed for date of service September 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the manual therapy techniques provided on October 22, 2021. 
 
You asked the Plan to pay for the manual therapy techniques. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that this service was already processed and paid by another 
provider. 
 
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. Review of the file shows that the Plan states that this service previously billed 
and paid to another provider. The documentation did not include proof of payment to another provider for this 
service. No additional documentation was provided to show that this service was previously paid. The Plan did 
not substantiate their denial. Therefore, we decided that the Plan has to pay for the manual therapy techniques 
provided on October 22, 2021.  
 
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 presbyopia correcting function of intraocular lens 
(V2788) provided September 6, 2022. 
 
You asked the Plan to pay for the presbyopia correct function. You say that you did not realize that you were 
getting an upgraded corrective lens and feel that the Plan should cover it. The Plan denied your request. The 
Plan says the presbyopia-correcting functionality of an IOL (V2788) is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the presbyopia 
correcting function of intraocular lens (V2788) provided September 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.  
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 13, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 6, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 6, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 19, 2022, through 
July 21, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the Plan should approve the admission 
and services rendered as medically necessary. The Plan denied your request. The Plan says that the enrollee 
could have been managed in the nursing facility where they reside, and at outpatient services. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found it was documented that the admitting physician was concerned for critical illness, acutely 
impairing at least one organ system (including cardiovascular, endocrine, metabolic, neurologic, and 
respiratory), with a high probability of imminent or life-threatening deterioration. The review indicates that the 
record showed that at the time of inpatient admission the admitting physician reasonably expected that the 
patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would 
span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from July 19, 2022, through July 21, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical boot/shoe you purchased on August 28, 2022. 
 
You asked the Plan to pay for the surgical boot/shoe. You say that you broke your toe and this shoe was 
needed.  This was the only way for you to get around, so it was medically necessary. The Plan denied your 
request. The Plan says the surgical boot/shoe you purchased (code L3260) is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that surgical shoes/boots are noncovered for all 
indications, regardless of the reason.  Further, your doctor billed this code with a GY modifier, indicating that 
they were aware this was not a covered item.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical boot/shoe have not been met. Therefore, we decided that the Plan does not have to pay 
for the surgical boot/shoe you purchased on August 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9366 billed for date of service September 
23, 2022, to September 29, 2022. 
 
You asked the Plan to pay for procedure code S9366. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9366 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9366 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9366 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9366 billed for date of service September 23, 2022, to September 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 20985-AS provided on May 25, 2022. 
 
You asked the Plan to pay for code 20985-AS. You say that the payment for these services should not have 
been reduced. The Plan denied your request. The Plan says no records were provided to show that surgical 
assistant services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of code 20985-AS have been met. 
Specifically, you have failed to supply any medical records at all supporting the need for the billed services, despite the Plan's request for those records. Therefore, we decided that the Plan does not have to pay for code 
20985-AS provided on May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 32562 provided on September 14, 2022. 
 
You asked the Plan to pay for procedure code 32562. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 32562 is instillation, via chest tube, agent for fibrinolysis. 
 
We find that CPT code 32562 is not supported in the medical record. Specifically, this service was provided 
within the 90 day global surgery period of code 44186. Based on this information, we decided that Medicare 
rules for coverage of procedure code 32562 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 32562 provided on September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor (A4239). 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day sensor. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14-day sensor (A4239).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service July 9, 2022. 
 
You asked the Plan to pay for procedure code 93042. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 29105. 
 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 93042 
is a column II code to column I code 29105. 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 93042 billed for date of service July 9, 2022.