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

 
We decided that the Plan does not have to waive the deductible for an office visit (99203) provided on October 
27, 2022. 
 
You asked the Plan to waive the deductible for the office visit. You say that this service should be covered. The 
Plan denied your request. The Plan says the correct cost sharing was applied. 
 
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 $100 
deductible for covered services. 
 
You have been asked to pay $85.05 for the office visit. The records show only $14.95 was paid towards the 
$100 deductible at the time these services were provided. 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 deductible 
for an office visit (99203) provided on October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for OON services have not been 
met. 
 
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 
a home ventilator (E0466) to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 provided on September 12, 2022. 
 
You asked the Plan to pay for procedure code 99214. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code 99214 is included in the global surgery 
payment for procedure code 27279 provided on June 21, 2022. Separate payment cannot be made for procedure 
code 99214 as code 99214 was not billed with the appropriate 24 modifier indicating that the denied service 
was unrelated and rendered during the post-operative period of a global procedure. Based on this information, 
we decided that Medicare rules for coverage of procedure code 99214 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99214 provided on September 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. 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 thermal destruction of the intraosseous BVN will 
be considered medically reasonable and necessary for the treatment of cLBP in patients who meet specific 
criteria. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. Therefore, the 
enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on April 14, 2022. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this code is part of the primary procedure and can't 
be paid. 
 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 95870-26-59 is a column II code to column I code 95861; however, 
95870-26-59 was billed with a modifier.  
 
We asked our coder 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 radiology services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the documentation states that a needle 
electromyography with or without paraspinal muscles was performed on bilateral legs, which was correctly 
reported with code 95861. This includes a limited study. The record does not support that a separate study was 
performed on separate limbs. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the radiology services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for radiological services provided on April 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee was admitted for lumbar compression fracture after a fall. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee was admitted for management of biliary obstruction. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 63081 billed for date of service May 11, 2022. 
 
You asked the Plan to pay for code 63081. You say that the billed code is correct and should be paid. The Plan 
denied your request. The Plan says code 63081 is not supported in the medical record. 
 
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 63081 is Vertebral corpectomy (vertebral body 
resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); 
cervical, single segment. 
 
We asked our coder 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 code 63081. Our reviewer says that this code is not supported 
in the medical record. Our reviewer found the medical records do not indicate that a vertebral corpectomy was 
performed. 
 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 63081 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 63081 billed for date of service May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee orthosis (L1851). 
 You asked the Plan to pre-approve the orthosis. You say that the provided records support the necessity of the 
service in dispute. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria. 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee was being treated for osteoarthritis. The enrollee presented with bilateral knee pain 
that is worse on the left. The pain has been present for many months. The pain is constant, aching, sharp, and 
throbbing. The exam of the left knee reveals the skin is mottled. There is decreased range of motion secondary 
to discomfort. There is minimal effusion. There is mild tenderness over the knee. X-rays are noted to show 
severe tricompartmental osteoarthritis with bone-on-bone articulation noted bilaterally, unchanged from the 
previous, no soft tissue edema or gangrene. However, detailed documentation is not evident regarding any 
instability on the left knee. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, the records do not show 
that the enrollee meets the Medicare criteria for the requested Knee brace L1851. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the knee orthosis (L1851).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic testing for severe inherited conditions 
(81443). 
 
You asked the Plan to pre-approve the genetic testing. You say that you are appealing the denial of the genetic 
testing and the records should support the necessity of the services. The Plan denied your request. The Plan 
says the records do not show that genetic testing is necessary and will alter the management of chorea. 
 
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 genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a diagnosis of other chorea, with severe hyperactive movement 
disorder of unclear etiology despite an extensive work-up. The enrollee has nonstop hyperactive movements 
that are involuntary and not distractable. The neurologist suggested doing a genetic panel, even though the risk 
of a genetic disorder is highly unlikely, given that the enrollee's identical twin is asymptomatic. The 
documentation does not support that genetic testing for severe inherited conditions is a clinically valid test for 
the enrollee's condition, and that the results will directly impact her treatment or 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the genetic testing for severe inherited conditions (81443).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9348 billed for date of service August 5, 
2022 to August 12, 2022. 
 
You asked the Plan to pay for procedure code S9348. You say that you have provided medical records to 
support payment. 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 S9348 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9348 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9348 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9348 billed for date of service August 5, 2022 to August 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation, beyond the 24 trip 
limit (A0170). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial as you will need additional transportation for physical and occupational therapy. The Plan denied 
your request. The Plan says your request exceeds the allowable transportation benefit. 
 
 
 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 24 routine transportation trips per year.   
 
We looked at your request, the records in the case file, and the Plans rules. Based on this information, we 
decided that the Plans rules for coverage of routine transportation have not been met. Specifically, the Plan 
contract provides coverage for up to 24 one-way routine transportation trips per year for non-emergency, 
medical-related purposes. Your request for additional trips exceeds the maximum allowable transportation 
benefit. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation, 
beyond the 24 trip limit (A0170).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the two skin biopsies performed by an in-
network provider on October 18, 2022. 
 
You asked the Plan to waive the deductible for the skin biopsies. You say that you think that these services 
should be covered. 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 says that you must pay the full cost for 
most covered services until you have paid the $500 deductible, and the deductible applies to in and out-of-
network outpatient surgery services. 
 
You have been asked to pay a $136.08 deductible for the two skin biopsies. The items or services you asked the 
Plan to waive the deductible for fall within the outpatient surgery and other medical services provided at 
hospital outpatient facilities and ambulatory surgical centers benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $500 deductible which applies to outpatient surgery and 
other medical services provided at hospital outpatient facilities and ambulatory surgical centers. This cost 
sharing is a contractual obligation that had not been met at the time the skin biopsies were performed on 
October 18, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the two skin 
biopsies performed by an in-network provider on October 18, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99284) provided on May 22, 2022. 
 
You asked the Plan to pay for the emergency room visit. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the documentation provided does not support the billed services. 
 
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 99284 is an emergency department visit with medical 
decision making of moderate complexity. 
 
We asked our coder 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 emergency room visit. Our reviewer says that the code 
billed is not supported by the records. Our reviewer found the provided records do not support that there was 
medical decision making of a moderate complexity. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the emergency room visit have not been met. Therefore, we decided that the 
Plan does not have to pay for an emergency room visit (99284) provided on May 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Barostim Neo system. 
 
You asked the Plan to pre-approve Barostim Neo system. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have 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 Barostim Neo system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary 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 Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Barostim Neo system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the single vision lenses provided on September 28, 2022. 
 
You asked the Plan to pay for the single vision lenses. You say that you were told that you would be 
reimbursed 50% if you went out-of-network. The Plan denied your request. The Plan says the benefit was 
exhausted.  
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 covers one pair of standard lenses and frames every two years. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for lenses on September 14, 2021, which 
exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the single 
vision lenses have not been met. Therefore, we decided that the Plan does not have to pay for the single vision 
lenses provided on September 28, 2022.