Persius/hicric huggingface dataset:
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 November 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests are included in the dialysis rate. 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 
November 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, G0483) provided on June 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (80307, G0483) provided on June 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (36415, 88262, 88230, 88289) provided 
on July 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical records. The Plan denied your request. The Plan says out-of-network services are only covered 
in certain limited circumstances which have not been met in this case. In addition, there are billing errors on 
this claim which would need to be corrected. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services (36415, 88262, 88230, 88289) 
provided on July 21, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without 
wheels, each (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that the enrollee needs this item as they are non-
weight bearing. You also say that the enrollee cannot use crutches. The Plan denied your request. The Plan says 
the requested item 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 a crutch substitute. Our reviewer says 
that the requested crutch substitute is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates that you require removal of orthopedic 
hardware and will be non-weight bearing in the affected lower extremity. The reviewer also found there is no 
documentation indicating that you cannot use crutches or a manual wheelchair for mobility. The documentation 
indicates you are noted to have full motor strength and can ambulate at baseline. Therefore, the requested 
crutch substitute, lower leg platform, with or without wheels 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 a crutch substitute have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crutch substitute, lower leg platform, with or without wheels, each (E0118).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman interspinous device placement. 
 
You asked the Plan to pre-approve the interspinous device placement. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 interspinous device placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is insufficient support in the medical literature demonstrating the safety and 
effectiveness of the Minuteman G3R Interspinous device. 
 
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 interspinous device placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Minuteman interspinous device placement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT cerebral perfusion studies (code 0042T) provided on 
September 26, 2022. 
 
You asked the Plan to pay for the CT cerebral perfusion studies. You say that the CT cerebral perfusion studies 
were medically necessary. The Plan denied your request. The Plan says the CT cerebral perfusion studies does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 CT cerebral perfusion studies. Our reviewer 
says that the CT cerebral perfusion studies is not medically necessary. Our physician reviewer found that the 
enrollee was not formally found to have an ICA or MCA occlusion based on the notes provided, it does not 
appear that the requirements for coverage of CTP were met in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT cerebral perfusion studies have not been met. Therefore, we decided that the 
Plan does not have to pay for CT cerebral perfusion studies (code 0042T) provided on September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wristband accessories associated with the Cala Trio nerve 
stimulator device (K1019) provided on September 20, 2022. 
 
You asked the Plan to pay for the wristband accessories associated with the Cala Trio nerve stimulator device. 
You say that the items are medically necessary. The Plan denied your request. The Plan says this is not a 
covered item. 
 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. Based on this information, we decided that Medicare rules for 
coverage of the wristband accessories associated with the Cala Trio nerve stimulator device have not been met. 
Specifically, no reimbursement may be made for the electric nerve stimulator or for the services related to its 
implantation since this treatment cannot be considered reasonable and necessary. Therefore, we decided that 
the Plan does not have to pay for the wristband accessories associated with the Cala Trio nerve stimulator 
device (K1019) provided on September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
May 16, 2022. 
 
You asked the Plan to pay for procedure codes 88341 and 88342. You say that these services were necessary 
and should be paid. The Plan denied your request. The Plan says payment for codes 88341 and 88342 is 
bundled into payment for code 88360. 
 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 
88341 and 88342 are column II codes to column I code 88360. These services have 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 88341 and 88342 billed for 
date of service May 16, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical controller (E2310) for an approved power 
wheelchair. 
 
You asked the Plan to pre-approve the electrical controller. You say that this feature is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when 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 electrical controller. Our reviewer says that this feature is not medically necessary. Our physician reviewer found the provided documentation 
does not reveal that the patient requires the joystick to control the power tilt as the patient can operate the 
power option through its own switches. 
 
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 controller have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electrical controller (E2310) for an approved power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assist for the wrist endoscopy (29848), provided 
on September 30, 2022. 
 
You asked the Plan to pay for the surgical assist for the wrist endoscopy. You say that the service was 
medically necessary. The Plan denied your request. The Plan says the service was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 29848. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
surgical assist for the wrist endoscopy have not been met. Therefore, we decided that the Plan does not have to 
pay for the surgical assist for the wrist endoscopy (29848), provided on September 30, 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 November 6, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. 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 November 6, 
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 November 
17, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim is billed correctly and should be 
paid. 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 for the HCPCS/CPT code will be denied. 
 
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. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
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 November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99310) provided on February 28, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that this service was medically necessary The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99310 is not supported in the medical record. Specifically, place of service 13 is not a 
valid place of service for this code. Based on this information, we decided that Medicare rules for coverage of 
the nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay for 
nursing facility care (99310) provided on February 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the discharge services (99238) provided on July 28, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that only one discharge 
code is payable per date of service, and 99239 has been billed and paid for the same date of service. 
 
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 only one discharge code is payable per date of service, and 
99239 has been billed and paid for the same date of service. However, the Plan has not provided documentation 
showing that code 99239 has been billed and paid for the date of service in question. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
discharge services (99238) provided on July 28, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99203) with an oncologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to be reevaluated with the 
requested provider due to a diagnosis of prostate cancer with metastasis to the bones. You would like to see this 
specialist to obtain other treatments or possible surgery. The Plan denied your request. The Plan says you must 
use an in-network provider to obtain services when available within the network. The services are available in-
network. 
 
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 
an office visit (99203) with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance service provided on July 1, 2022. 
 
You asked the Plan to pay for the air ambulance service. You say that the medical records provided support the 
need for the air ambulance transport. The Plan denied your request. The Plan says the plan says the air 
ambulance transport was not medically necessary. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance service. Our reviewer says 
that the air ambulance service was not medically necessary. Our physician reviewer found the enrollee fell and 
suffered a hip fracture. The sending facility did not have orthopedic services, necessitating a transfer. While the 
transfer itself was warranted, the use of an air ambulance was not. The mechanism of trauma was minor. The 
enrollee was clinically stable. Transport could have been performed by a ground ambulance without an 
expected decline in the enrollee's condition. 
 
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 air ambulance service have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance service provided on July 1, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve ultrasound hepatic elastography (76981, 76983). 
 
You asked the Plan to pre-approve FibroScan. You say that confirming the enrollee's suspected diagnosis with 
a non-invasive tool is preferred over a biopsy. You also say that establishing the diagnosis is important in 
beginning a monitoring path. The Plan denied your request. The Plan says that the requested services are not 
medically necessary. 
 
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 FibroScan. Our reviewer says that the 
requested FibroScan is considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested non-invasive assessment of hepatic fibrosis by FibroScan (CPT 76981) is standard of care 
and medically necessary to delineate the enrollee's extent of liver injury given the inconsistency between 
radiologic imaging and lab studies. Therefore, the reviewer found that the requested FibroScan is medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of FibroScan have been met. Therefore, we decided that the Plan has to pre-
approve ultrasound hepatic elastography (76981, 76983).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral sacroiliac (SI) joint injection (27096). 
 
You asked the Plan to pre-approve a SI joint injection. You say that when your pain flares up you are in pain to 
the point of needing narcotics to do simple chores. You say that you do not like to take the narcotics, but it is 
the only way you can somewhat function. You also say that the injections will take the pain away immediately. 
The Plan denied your request. The Plan says the requested injections are 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 a SI joint injection. Our reviewer says 
that the requested SI joint injection is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation on physical examination of tenderness of the SI joint. The 
documentation does not mention SI provocative testing being completed with positive findings. The clinical 
value and effectiveness of an SI joint injection in the absence of tenderness and negative provocative testing 
results have not been demonstrated in the peer-reviewed literature. Therefore, the reviewer found that the 
requested injection 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 a SI joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a bilateral sacroiliac (SI) joint injection (27096).