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

 
We decided that the Plan does not have to pay for introduction/injection of anesthetic agent (nerve block), 
diagnostic or therapeutic procedures on the paravertebral spinal nerves and branches (code 64495) provided on 
October 3, 2022. 
 
You asked the Plan to pay for introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic 
procedures on the paravertebral spinal nerves and branches. The Plan denied your request. The Plan says the 
need for three or four levels bilaterally may be considered under unique circumstances and with sufficient 
documentation of medical necessity. The provider did not provide evidence of such a unique circumstance. 
 
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 introduction/injection of anesthetic agent 
(nerve block), diagnostic or therapeutic procedures on the paravertebral spinal nerves and branches. Our 
reviewer says that introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic procedures 
on the paravertebral spinal nerves and branches is not medically necessary. Our physician reviewer found that 
according to the Medicare coverage criteria: One to two levels, either unilateral or bilateral, are allowed per 
session per spine region. The need for a three or four-level procedure bilaterally may be considered under 
unique circumstances and with sufficient documentation of medical necessity on appeal. A session is a time 
period, which includes all procedures (i.e., medial branch blocks (MBBs), intraarticular injections (IA), facet 
cyst ruptures, and RFA ablations) that are performed during the same day. In this case, the provider did not 
provide evidence of unique circumstances for a third level with sufficient documentation of medical necessity. 
The review has determined that the requested facet joint injection did not meet the Medicare LCD coverage 
criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of introduction/injection of anesthetic agent (nerve block), diagnostic or 
therapeutic procedures on the paravertebral spinal nerves and branches have not been met. Therefore, we 
decided that the Plan does not have to pay for introduction/injection of anesthetic agent (nerve block), 
diagnostic or therapeutic procedures on the paravertebral spinal nerves and branches (code 64495) provided on 
October 3, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the infectious agent detection by nucleic acid (DNA or RNA); severe 
acute respiratory syndrome coronavirus 2 (SARS-COV-2) (Coronavirus disease (COVID-19)), amplified probe 
technique (U0005) provided September 3, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that per California Senate Bill 510, Health Plans 
are at risk for Covid-19 diagnostic test claims. Please process for payment. The Plan denied your request. The 
Plan says that the records do not show that a physician ordered the test. The records do not establish medical 
necessity for the test. 
 
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 has not provided any information to substantiate their reason to 
continue to deny the services. The provided Case Summary also indicates that medical records were not 
requested from the providers. Without records, we are unable to determine medical necessity. Therefore, we 
decided that the Plan has to pay for the infectious agent detection by nucleic acid (DNA or RNA); severe acute 
respiratory syndrome coronavirus 2 (SARS-COV-2) (Coronavirus disease (COVID-19)), amplified probe 
technique (U0005) provided September 3, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for December 2, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intraoperative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same day as 
minor surgical procedure billed with code 62323. Payment for code J3490 is included in the global surgical 
package for code 62323. Therefore, we decided that the Plan does not have to pay for procedure code J3490 
billed for December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service October 4, 
2022. 
 
You asked the Plan to pay for procedure code 99213. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99213 is bundled into payment for code 96365. 
 
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 99213 
is a column II code to column I code 96365. 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 99213 billed for date of service October 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75625, 75716, and 75774 billed for 
September 23, 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 75625 is aortography, abdominal, by serialography, 
radiological supervision and interpretation. 
 
We find that CPT code 75625 is not supported in the medical record. Specifically, there is no documentation of 
radiological supervision and interpretation of an abdominal aortography by serialography. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. 
 
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 75716 and 75774 are column II codes to 
column I code 37220. This claim has not been billed with an appropriate modifier to bypass the edit. The -59 
modifier is not supported as a separate and distinct procedural service. 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 75625, 75716, and 75774 billed 
for September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 87801 provided on June 22, 2022. 
 
You asked the Plan to pay for code 87801. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are 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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, the coding does not support 
three units of 87801. The documentation notes two test results. Based on this information, we decided that 
Medicare rules for coverage of code 87801 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 87801 provided on June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ottobock Cleg 4 microprocessor knee (L5828, 
L5845, L5848, L5856). 
 
You asked the Plan to pre-approve a microprocessor knee. You say that the prosthesis will also have a positive 
impact on the enrollee's overall health and reduce the pressures and strain on the enrollee's sound leg. You say 
that a K3 level prosthesis will also decrease the risk of the enrollee getting pressure ulcers or joint contractures 
when seated for lengthy periods of time. The Plan denied your request. The Plan says a microprocessor knee is 
not medically necessary for the enrollee. 
 
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 microprocessor knee. Our reviewer 
says that the requested microprocessor knee is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested microprocessor knee exceeds the enrollee's medical needs. The 
reviewer found that while the enrollee is a K3 ambulatory, the documentation does not reveal that the patient 
requires a heavier microprocessor K3 knee over a K3 mechanical knee. Therefore, the reviewer found that a 
microprocessor knee 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 microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Ottobock Cleg 4 microprocessor knee (L5828, L5845, L5848, L5856).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
13, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service should be covered under the 
surgeon's authorization. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy (97012), physical therapy 
treatment (97039), and the manual therapy techniques (97140) provided from April 26, 2022, through 
September 7, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the mechanical traction therapy (97012), physical therapy treatment 
(97039), and the manual therapy techniques (97140) provided from April 26, 2022, through September 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system (L5981) for a lower limb prosthesis. 
 
You asked the Plan to pre-approve flex-walk system. You say that the enrollee needs this. The Plan denied 
your request. The Plan says the record does not support that the enrollee is a level 3 ambulator. 
 
The Plan follows Medicare rules. Medicare rules state that a flex-walk system is covered for enrollees whose 
functional level is 3 or above. 
 
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 flex-walk system. Our reviewer says 
that the enrollee does not meet criteria for the requested flex-walk system. Our physician reviewer found the 
documentation does not support that the enrollee can walk at functional level 3. There is insufficient 
documentation regarding the enrollee's current level of mobility, but clinical progress notes indicate the 
enrollee ambulates with the assistance of a cane. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of flex-walk system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a flex-walk system (L5981) for a lower limb prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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. 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. You could be treated with a bilevel positive airway pressure (BiPAP) machine with average volume-
assured pressure support (AVAPS) capability. The elements of the coverage criteria are not satisfied. The 
requested service cannot be 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital stays provided from 
April 4, 2022, to June 7, 2022. 
 
You asked the Plan to waive the copayments for the inpatient hospital stays. You say that you feel you should 
not have to pay for each stay as they were all for related issues. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $465 
copayment per day for days 1-4 of each in-network inpatient hospital stay.  
 
You have been asked to pay a $465 copayment per day for days 1-4 of the inpatient hospital stay provided from 
April 4, 2022, to April 12, 2022. You have also been asked to pay a $465 copayment per day for days 1-4 of 
the inpatient hospital stay provided from May 18, 2022, to June 7, 2022. You have been asked to pay a total of 
$1,860 for each inpatient hospital stay ($465 copayment per day x 4 days = $1,860). These items/services fall 
within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for 
the inpatient hospital stays provided from April 4, 2022, to June 7, 2022.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 36 routine transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 36 routine transportation trips. You say that you need 
transportation for medical appointments. The Plan denied your request. The Plan says the transportation benefit 
only allows 72 trips for this service. You have used 53 trips and have 19 remaining. This request exceeds your 
benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 36 routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 provided on March 28, 2022. 
 
You asked the Plan to pay for procedure code 94761. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that procedure code 94761 has a status indicator of T on the Physician Fee Schedule. There was 
another payable service billed on the same date by the same provider. This means that procedure code 94761 is 
not separately payable. Therefore, we decided that the Plan does not have to pay for procedure code 94761 
provided on March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says the 
enrollee has not had a cryptogenic stroke. 
 
The Plan follows Medicare rules. Medicare rules say that electrocardiographic services are only covered under 
certain medical indications.  
 
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 requested service. Our physician 
reviewer found that the enrollee has a history of atrial fibrillation. A subcutaneous insertion of an implantable 
cardiac monitor (ICM), also referred to as an implantable loop recorder (ILR) was requested. There is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ICM. There is insufficient documentation to support the medical necessity for insertion of an 
ICM in this enrollees clinical management. 
 
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 requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an implantable loop recorder.
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 you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be met in other settings. 
 
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 need physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as skilled nursing 
facility. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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. 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume-assured pressure support (AVAPS) capability. The elements of the coverage criteria are not satisfied. 
The requested service cannot be 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.