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

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve. 
 
You asked the Plan to pre-approve intraosseous ablation of the basivertebral nerve. You say that intraosseous 
ablation of the basivertebral nerve is medically necessary. The Plan denied your request. The Plan says 
intraosseous ablation of the basivertebral nerve 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 intraosseous ablation of the 
basivertebral nerve. Our reviewer says that intraosseous ablation of the basivertebral nerve is not considered 
medically reasonable and necessary. Our physician reviewer found that the Intracept procedure targets the 
basivertebral nerve for the relief of chronic vertebrogenic low back pain. Medicare guidelines consider this 
type of system unproven and not medically necessary. Large well-designed studies in the peer review scientific 
literature comparing stand-alone use of an Intracept device to established surgical decompression are 
needed. Published studies do not demonstrate any long-term health outcome advantage with the use of 
Intracept as an alternative to standard surgical treatment. The review has determined that the requested Intracept procedure is not medically reasonable or necessary for the enrollee 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 intraosseous ablation of the basivertebral nerve have not been met. Therefore, 
we decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81295 & 81298 billed for date of service 
December 29, 2021. 
 You asked the Plan to pay for procedure code 81295 & 81298. You say that the services were medically 
necessary. The Plan denied your request. The Plan says payment for code 81295 & 81298 is bundled into 
payment for code 81432. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
81295 & 81298 are column II codes to column I code 81432. 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 codes 81295 & 81298 billed for date of 
service December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 84436 and 84479 billed for date of service July 28, 
2021. 
 
You asked the Plan to pay for codes 84436 and 84479. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says codes 84436 and 84479 are bundled into 
payment for code 84439. 
 
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 84436 
and 84479 is a column II code to column I code 84439 with a modifier indicator of 0. The column II code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 84436 and 84479 billed for date of service July 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on February 11, 2021, and 
February 12, 2021. 
 
You asked the Plan to pay for the radiology services. You say that these services were not related to the 
patient's hospice plan of care. The Plan denied your request. The Plan says the patient was enrolled in hospice 
on these dates of service, which is why payment was retracted for these services. Non-hospice services should 
be billed to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for radiology services provided on February 11, 2021, and 
February 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered on February 
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 the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services rendered on 
February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81521 billed for date of service May 18, 
2022. 
 
You asked the Plan to pay for procedure code 81521. You say that two separate tumors were sent to your lab 
for testing. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. The Plan has already paid for 1 unit of 81521 on August 11, 2022.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 81521 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 81521 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 81521 billed for date of service May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional routine-transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that the request is a necessity for your care. The 
Plan denied your request. The Plan says you have exhausted the routine transportation benefit for the year. 
 
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 20 one-way 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 10 additional routine-transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Conformis customized knee implant and an inpatient 
stay. 
 
You asked the Plan to pre-approve a Conformis customized knee implant and an inpatient stay. 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 a Conformis customized knee implant 
and an inpatient stay. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, 
long-term peer-reviewed literature that shows Conformis customized knee implant to be an effective treatment 
for use in total knee replacements. As the requested procedure is not supported, the associated inpatient stay 
would not be indicated. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Conformis customized 
knee implant (CPT 27447) and the inpatient stay, in this case, are 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 Conformis customized knee implant and an inpatient stay have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Conformis customized knee implant and an 
inpatient stay.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided on June 22, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the services at issue were billed correctly. The 
Plan denied your request. The Plan says that rules for payment have not been met. 
 
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 Plan's denial in this case states that a mileage code was not 
billed for the date of service at issue. The claim available in the case record includes mileage code A0425 
billed for date of service June 22, 2022. The Plan has not provided any other reason why ambulance services 
should not be paid. It is the Plan's responsibility to substantiate its denial with evidence. In this case, the denial 
has not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for 
ambulance services provided on June 22, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom-fabricated abutment (D6057) and a crown 
restoration supported by an abutment (D6058). 
 
You asked the Plan to pre-approve a custom-fabricated abutment and a crown restoration supported by an 
abutment. You say that the request is a medical necessity for you. The Plan denied your request. The Plan says 
the requested services are not a covered benefit. 
 
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 pre-approve a 
custom-fabricated abutment (D6057) and a crown restoration supported by an abutment (D6058).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (73502) provided on October 6, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this service was previously paid and is not eligible for separate 
payment. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan under claim number 820221130108942. Comparison of the two claims shows these are 
exact duplicates. There is no evidence presented to support that the billed items/services were provided twice 
on the same date. Based on this information, we decided that the Medicare rules for the radiology services have 
not been met. Therefore, we decided that the Plan does not have to pay for radiology services (73502) provided 
on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (27096) provided on July 20, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this service is not eligible for payment in the ambulatory surgical 
center setting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 27096 is not supported in the medical record. Specifically, procedure code 27096 is not 
included on the Ambulatory Surgical Center Covered Surgical Procedures list for 2021. Based on this 
information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, 
we decided that the Plan does not have to pay for surgical services (27096) provided on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) 
provided June 10, 2022 
 You asked the Plan to pay for the electrical stimulator supplies. You say that please review the claim denial for 
accuracy. The Plan denied your request. The Plan says evidence of misrepresented services. 
 
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 pay for the electrical stimulator supplies. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the reviewed documentation indicates that the Plan reached out to the 
enrollee on August 27, 2022, and asked if the enrollee received electrical stimulator supplies, 2 lead, per month 
from the supplier. The enrollee responded that electrical stimulator supplies was received in May. It infers the 
enrollee did not receive any order in June. There is no specific clinical rationale for the requested items. The 
enrollee was receiving physical therapy for right shoulder pain and weakness. The review has determined that 
the medical records provided did not meet the requirements listed in the LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the electrical stimulator supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month (A4595) provided June 
10, 2022
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 February 22, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this is a payable charge. 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 February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 28, 2021, to December 31, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
medically necessary. The Plan denied your request. The Plan says after reviewing the medical record for clinical validation of metabolic encephalopathy, sufficient supporting documentation was not found within the 
submitted medical record to validate this diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with a diagnosis of metabolic encephalopathy. We asked 
our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally 
billed. Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that in this case there was no clinical or laboratory evidence of metabolic 
encephalopathy. The review has determined that the records did not support G93.41 - metabolic 
encephalopathy - as a valid diagnosis for this inpatient stay.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from December 28, 2021, to December 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 27, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service should be covered. 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 81. 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 May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 21, 2022, to 
May 23, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
patient met criteria for the sepsis diagnosis. The Plan denied your request. The Plan says the principal diagnosis 
code assignment of A41.9 Sepsis, unspecified organism was reported by the hospital. According to coding 
guidelines and documentation in the medical record this condition did not qualify for reporting as the principal 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with the principal diagnosis code assignment of A41.9 
(Sepsis, unspecified organism). We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that the principal diagnosis code of A41.9 
Sepsis, unspecified organism is not supported in the medical record. Our physician reviewer found the enrollee 
was a then, 73-year-old female with a past medical history of chronic obstructive pulmonary disease on 2L of 
oxygen at home. She presented to the emergency room with a complaint of shortness of breath. Her imaging 
was consistent with pneumonia. In the emergency room, she was given 3L of IV fluids, started on supplemental 
oxygen and IV antibiotics. Sepsis is a life-threatening syndrome usually caused by bacterial infection. Sepsis is 
a response of the body's immune system that results in organ dysfunction or failure. The systemic inflammatory 
response syndrome (SIRS) criteria were recently replaced by the quick Sequential Organ Failure Assessment 
(qSOFA) in 2016, allowing for quick bedside analysis of organ dysfunction in patients with suspected or 
documented infection. The qSOFA score includes a respiratory rate of 22 breaths/minute or more, systolic 
blood pressure of 100 mm Hg or less, and altered level of consciousness. For completeness, severe sepsis is 
defined as sepsis complicated by organ dysfunction. In this case, while the member's presentation warranted 
consideration of sepsis as a diagnosis, there was no evidence of life-threatening organ dysfunction due to a 
dysregulated host response to infection.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 21, 2022, to May 23, 2022, at the Diagnosis Related Group 
(DRG) originally billed.