Persius/hicric huggingface dataset:
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 you cannot walk or care for yourself. The Plan 
denied your request. The Plan says the denial of IRF care is correct. 
 
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 complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may be physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy 
program. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional six (6) CMT; spinal, 3-4 regions visits (98941 
X6). 
 
You asked the Plan to pre-approve the additional chiropractic visits. You say that the services are medically 
necessary. The Plan denied your request. The Plan says you already had five (5) visits and another one is 
scheduled on March 9, 2023. The Plan states more than six chiropractic maintenance therapy visits that have 
been requested, are not included in your evidence of coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at the file and Medicare rules. Your 2023 EOC states that covered services include: Routine 
chiropractic care, up to six supplemental visits per year: Six routine chiropractic visits include manual 
manipulation for maintenance chiropractic care. After your visit on March 9, 2023, you will have exhausted 
your benefit. Therefore, we decided that the Plan does not have to pre-approve additional six (6) CMT; spinal, 
3-4 regions visits (98941 X6).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 20, 2021. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on October 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of the Coflex interspinous device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the Coflex interspinous device in the setting of 
lumbar stenosis has not been demonstrated in the peer-reviewed literature. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. 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 requested Coflex interspinous 
device at the L4-5 level, 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the implantation of the Coflex interspinous device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not support that you require skilled nursing services with the 
specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively provide care 
only in a SNF. You do not have complex wound care, intravenous (IV) antibiotics, enteral feedings or other 
skilled nursing (SN) need during these dates that require a SNF admission. Your functional level does not 
require the skills of a professional therapist only in a SNF. You do not require skilled nursing or skilled therapy 
on a daily basis. As a practical matter, your needs do not require the necessary services on an inpatient basis in 
a SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service August 22, 
2022. 
 
You asked the Plan to pay for procedure code 88305. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is 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 code 88305. This means there 
is both a professional and technical component for the CPT code. In this case, an appropriate modifier to 
indicate the professional component has not been billed with CPT code 88305. Based on this information, we 
decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 88305 billed for date of service August 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 17, 2022, 
to March 18, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 17, 2022, to 
March 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve quantitative calcium scoring (75571). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says calcium scoring reported in isolation is considered a screening service. 
 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. 
 
Medicare does not cover calcium scoring reported in isolation becaise it is considered a screening service. 
Therefore, we decided that the Plan does not have to pre-approve quantitative calcium scoring (75571).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 31, 
2022. 
 
You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 31, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery 
(22869). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 service. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the Vertilfex device is experimental. More research is needed. 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new foot system (L5981/L5968). 
 
You asked the Plan to pre-approve a new foot system. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested items are not more than 5 years or irreparable. Therefore, coverage 
criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for the least expensive option of 
repair vs. replacement of durable medical equipment (DME). Replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a new foot system have not been met. Therefore, we decided that the Plan does not have to pre-
approve a new foot system (L5981/L5968).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service June 28, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this service was medically necessary. The 
Plan denied your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service June 28, 2022, billed with 
code 99153.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service September 
20, 2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
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 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. One unit was billed on claim 820222820034371, which was processed and paid by 
the Plan. Another unit was billed on claim 820222980073807, which exceeds the MUE for this code. Based on 
this information, we decided that Medicare rules for coverage of procedure code 99291 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99291 billed for date of service 
September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary and supported by strong science. The Plan denied your request. The Plan says the Intracept 
procedure is unproven and 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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation 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. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 29, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on September 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services billed on November 24, 2022. 
 
You asked the Plan to pay for the radiology services billed. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
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 on December 10, 2022. 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 billed have not been 
met. Therefore, we decided that the Plan does not have to pay for radiological services billed on November 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92556 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 92556. The Plan denied your request. The Plan says payment for 
code 92556 is bundled into payment for code 92553. 
 
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 92556 
is a column II code to column I code 92553 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 procedure code 92556 billed for date of service September 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code(s) 88305. The Plan denied your request. The Plan says this code 
is included in the facility payment and is 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 code(s) 88305. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service August 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on September 7, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this item is 
not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on 
September 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral open sacral iliac joint fusion. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requirements 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records do not show sacroiliac joint instability fracture or lesion. Sacroiliac joint fusion for 
degenerative back pain is experimental. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral open sacral iliac joint fusion.