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

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint - bilateral 
L3-L4 (64636) 
 
You asked the Plan to pre-approve the radiofrequency ablation (RFA) procedure. You say that the medical 
records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says 
radiofrequency ablation at this level is not reasonable or necessary at this time. 
 
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 radiofrequency ablation procedure. 
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 chronic axial lumbar pain and the diagnoses of 
sacroiliitis and spondylolisthesis at multiple sites in spine. The request is to perform RFA bilaterally at the L3-
L4 and L4-L5 levels. RFA at the L4-L5 level has been approved as medically necessary. The enrollee has 
undergone two sets of diagnostic medial branch block (MBB) bilaterally at levels L4-L5 and L5-S1 with 
another physician on January 8, 2021, and February 9, 2021, which provided 80% pain relief for 5 hours. The 
medical record also shows the enrollee has undergone one set of MBBs bilaterally at level L3-L4, which is this 
level being requested for this RFA, with another provider on May 26, 2020 (left side) and June 2, 2020 (right 
side) with a reported 80% pain relief. Taking into account all of these procedures, the enrollee has only 
undergone one set of MBBs bilaterally at the L3-L4 level.  At the L3-L4 level only one set has been performed.  
Therefore, the request to do this level is, at this point, is deemed medically not 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 the radiofrequency ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint - bilateral 
L3-L4 (64636)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral - 
periapical each additional radiographic image (D0230 x5) provided on August 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware the dentist was out-of-
network. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation was exhausted on date of service September 30, 2020 
and the additional radiographic image (D0230 x6) was exhausted on the original request.  Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), and intraoral - periapical each additional radiographic image (D0230 x5) 2022. The Plan agreed to 
pay for the additional radiographic image (D0230 x1) provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220) 
provided on August 22, 2022. 
 
You asked the Plan to pay for an intraoral - periapical first radiographic image (D0220). You say that you have 
submitted the information needed. The Plan denied your request. The Plan says there is no coverage for this 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
intraoral - periapical first radiographic image (D0220) provided on August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a memory seat. 
 
You asked the Plan to pre-approve a memory seat. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a memory seat.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99202), manual therapy techniques (97140), and the 
therapeutic exercises (97110) provided from September 19, 2018, through December 18, 2018. 
 
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 that these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plans contract includes supplemental coverage for medically 
necessary therapy. The Plan has denied the claim for these services. However, the Plan has not provided 
medical records to our organization to determine the medical necessity of the therapy services provided in this 
case. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided 
that the Plan has to pay for the office visit (99202), manual therapy techniques (97140), and the therapeutic 
exercises (97110) provided from September 19, 2018, through December 18, 2018.  
 
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 pay for the office visit (99203) provided on July 6, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is 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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a calf rest or pad (E0995) for a power wheelchair. 
 
You asked the Plan to pre-approve a calf rest. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a Column II code is included in the allowance for 
the corresponding Column I code when provided at the same time. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a calf rest have not been met. Specifically, the item coded E0995 is included in the allowance for 
the approved Group 3 standard power wheelchair with single power option coded as K0856. Therefore, we 
decided that the Plan does not have to pre-approve a calf rest or pad (E0995) for a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360 and 88381 billed for 
date of service April 1, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88360 and 88381. You say that the services at 
issue have been billed correctly. The Plan denied your request. The Plan says these codes are included in the 
facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360 
and 88381. This means there is both a professional and technical component for the CPT codes. In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT codes 88341, 88342, 
88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure codes 
88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 88341, 88342, 88360 and 88381 billed for date of service April 1, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the code is not inclusive with other codes 
billed. The Plan denied your request. The Plan says procedure code 99053 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 procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99053 billed for date of service March 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete ultrasound study of arm and leg arteries. 
 
You asked the Plan to pre-approve the ultrasound. You say that the enrollee needs to have an updated 
segmental pressure for continued surveillance of their arterial disease. The Plan denied your request. The Plan 
says the Medicare guidelines were not met, and the test 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 the ultrasound. Our reviewer says that 
the documentation does not support the medical necessity of the code requested. Our physician reviewer found 
that the enrollee has a history of significant peripheral artery disease with documented ankle-brachial indexes 
(ABI) of 0.69 on the right and 0.81 on the left on August 11, 2021. Although the enrollee is documented to be 
asymptomatic, yearly surveillance of their significant peripheral artery disease is reasonable. The enrollee's 
provider has recommended follow-up with ABIs, a reasonable plan. The service code requested however is 
93923, a code used to designate a 3 or more-level physiologic study. This is a more complex and more 
expensive code then what the provider has determined is necessary. Recommend resubmitting with the 
appropriate code to match the providers request. 
 
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 ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a complete ultrasound study of arm and leg arteries.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73560 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 73560. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 73560 is bundled into payment for 
code 73562. 
 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 73560 
is a column II code to column I code 73562. 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 73560 billed for date of service July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic carrier screening tests provided on May 2, 2022. 
 
You asked the Plan to pay for the genetic carrier screening tests. You say that this testing was medically 
necessary and should be covered. The Plan denied your request. The Plan says these screening tests are not 
covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the genetic carrier screening tests, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for genetic carrier screening tests provided on May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy service provided on June 
7, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy service. You say that you have not received 
this service. 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 $60 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $60 copayment for radiation therapy service. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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 copayment for radiation therapy service provided on June 7, 2022.  
 Your complaint about never received services from this provider on this date is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
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 services are medically necessary. The Plan 
denied your request. The Plan says based on your current level of function, you do not require an intensive, 
complex, multidisciplinary approach to daily therapy. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam provided on October 
7, 2021. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that this was your yearly exam 
and there should be no copayment. 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 $40 
copayment for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $40 copayment for the medical eye exam. This medical eye exam falls within the 
Medicare-covered exams to diagnose and treat diseases and conditions of the eye benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The medical record 
shows diagnoses including posterior vitreous detachment and dry macular degeneration which makes the eye 
exam medical in nature. 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 copayment for the medical eye exam 
provided on October 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve implantable loop recorder. You say that the implantable loop recorder is 
needed for long-term cardiac dysrhythmia monitoring and to evaluate the burden of atrial fibrillation. The Plan 
denied your request. The Plan says the enrollee does not have a covered indication for an implantable loop 
recorder. 
 
The Plan follows Medicare rules. Medicare rules state that an implantable loop recorder may be covered when 
syncope is thought to be cardiac-related but is too infrequent to be detected by a traditional memory loop 
recorder. 
 
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 implantable loop recorder. Our 
reviewer says that the enrollee does not meet the Medicare criteria for an implantable loop recorder. Our 
physician reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent indication for 
an implantable loop recorder. In summary, there is insufficient documentation to support the medical necessity 
of an implantable loop recorder 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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 22855 provided on June 23, 2022. 
 
You asked the Plan to pay for procedure code 22855. You say that the medical records support the billing of 
code 22855. The Plan denied your request. The Plan says that the medical records do not support the billing of 
code 22855. 
 
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 22855 is Removal of anterior instrumentation. 
 
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 procedure code 22855. Our reviewer says that the medical 
records support the billing of code 22855. Our reviewer found the procedure details an incision was made and 
the supraplatysmal (indicating anterior) flap was raised. A Kittner was used as well as the Bovie to clear the 
soft tissue off the plate. Locking mechanism was taken off the screws. The screws were backed out and then 
the plate was removed. Therefore, the medical records do support the billing of code 22855: removal of 
anterior instrumentation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 22855 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 22855 provided on June 23, 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.