Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 88237 and 88264. We decided that the Plan does not 
have to pay for procedure code 88185-91.  
 
You asked the Plan to pay for procedure codes 88185-91, 88237 and 88264 billed for date of service March 28, 
2022. You say that these services were reported appropriately, and the enrollee was referred for these services 
by an in-network provider. The Plan says that code 88185-91 was not coded correctly, code 88237 was not 
billed with an appropriate diagnosis and code 88264 was not prior authorized. 
 
We decided that the Plan has to pay for procedure codes 88237 and 88264.  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for laboratory services (88237 and 88264) by a contract provider. The file does not 
show that the plan provided notice that these services would not be covered. Under Medicare rules, this means 
the laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for 
procedure codes 88237 and 88264.  
 
We also decided that the Plan does not have to pay for procedure code 88185-91. 
 
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 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 88185-91. Our reviewer says that this service 
is not supported as billed. Our reviewer found that the 23 units of 88185-91 cannot be verified in this case. 
Also, modifier 91 cannot be verified, as only one laboratory procedure was found in medical record.  
 
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 88185-91 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88185-91. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine surgery. 
 
You asked the Plan to pre-approve spine surgery. 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 spine surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested lumbar spinal fusion with 
decompression and allograft at L4/5, in this case, 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 spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spine surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 provided on July 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 99232. The Plan denied your request. The Plan says payment for 
code 99232 is bundled into payment for code 99239. 
 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 99232 
is a column II code to column I code 99239. 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 99232 billed for date of service July 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan. 
 
You asked the Plan to pre-approve Xifaxan. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan.  
 
Benefits for Xifaxan may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation and emergency 
care provided on August 5, 2021. 
 
You asked the Plan to waive the copayment for ambulance transportation and emergency care. You say that 
you believe this was COVID-19 related and hope the services will 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 clearly says that you must pay $250 
copayment for each in- and out-of-service area one-way Medicare-covered ambulance transport and $90 
copayment for each in- and out-of-service area Medicare-covered emergency room visit.  
 
  You have been asked to pay a total of $340 for ambulance transportation and emergency care ($250 + $90 = 
$340). This ambulance transportation and emergency care falls within the Emergency care and Ambulance 
services 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 ambulance transportation 
and emergency care provided on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of basivertebral nerve (Intracept) 
procedure (64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure fills a treatment gap for 
those that do not receive adequate relief from traditional conservative methods and do not have instability to 
indicate fusion is the appropriate treatment. The Plan denied your request. The Plan says the requested 
procedure 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered experimental and investigational. Therefore, 
the reviewer found that an Intracept procedure is not medically 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intraosseous ablation of basivertebral nerve (Intracept) procedure (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that you disagree with the denial. It is 
medically necessary, and FDA approved. The Plan denied your request. The Plan says the clinical value and 
effectiveness of the MyoPro orthotic device in the setting of left hemiparesis secondary to cerebral infarction 
have not been demonstrated in the peer-reviewed literature. Neither Medicare nor the health plan covers this 
request. Medical studies haven't proven this service/item is helpful for the treatment of the enrollees health 
problem. 
 
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 MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. 
There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for this enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667, 
E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652, E0667, E0656).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. 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 follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does not reveal clear failure of 4 weeks of conservative care. The physical exam is not clear on a specific level 
or laterality of a radiculopathy for this injection. The criteria for this epidural have not been met. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve a SI joint injection. You say that the services are necessary. The Plan denied 
your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have 
not been met. 
 
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 a SI joint injection. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has 3 physical exam tests documented. He is taking Mobic, a nonsteroidal 
antiinflammatory drug (NSAID) and Gabapentin, an anti-convulsant. He had prior physical therapy. The 
request 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 a SI joint injection have been met. Therefore, we decided that the Plan has to 
pre-approve a sacroiliac (SI) joint injection.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport service provided on January 24, 
2022. 
 
You asked the Plan to pay for the ambulance transport service. You say that you have submitted medical 
records for reconsideration. The Plan denied your request. The Plan says the claim was processed correctly 
based on the Explanation of Benefits (EOB) not attached to the claim. The primary EOB is required to process 
the claim, and diligent effort was made to obtain it but was not received. 
 
  
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
primary insurance carrier to obtain payment information, but primary insurance payment information has not 
yet been submitted. As the secondary insurer, the Plan cannot be held responsible for the ambulance transport 
service until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for the ambulance transport service provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma (PRP) injection (0232T). 
 
You asked the Plan to pre-approve PRP injection. You say that the requested treatment is medically necessary 
for the enrollee to get pain relief. The Plan denied your request. The Plan says the requested treatment 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 PRP injection. Our reviewer says that 
the requested PRP injection is not considered medically reasonable and necessary in this case. Our physician reviewer found PRP injections are considered experimental for musculoskeletal pain. Therefore, the reviewer 
found that the requested PRP injection is not medically necessary 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 PRP injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve platelet rich plasma (PRP) injection (0232T).
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 following the hip fix you demonstrate decreased 
function and are unable to return home safely. You would benefit from IRF for intensive therapy services and 
medical oversight to decrease risk of infection and decrease risk for re-hospitalization. The Plan denied your 
request. The Plan says the request is not medically necessary, you can safely receive the services you need in 
other settings, for example: a skilled nursing facility. 
 
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. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36012 billed for date of service May 29, 
2022. 
 
You asked the Plan to pay for procedure code 36012. The Plan denied your request. The Plan says payment for 
code 36012 is bundled into payment for code 37182.  
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 36012 
is a column II code to column I code 37182. 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 36012 billed for date of 
service May 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on September 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 nursing facility care provided on September 15, 
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 back-up battery for a continuous positive airway 
pressure (CPAP) device. 
 
You asked the Plan to pre-approve a CPAP back-up battery. You say that the requested item is a necessity for 
your care. The Plan denied your request. The Plan says the requested item does not serve a medical purpose. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a back-up battery for a CPAP device.