Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services provided on May 26, 2022. 
 
You asked the Plan to pay for the services provided. You say that the charges were appropriate for the services 
provided. The Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code A4930 is gloves, sterile, per pair. Payment for this code 
is packaged into payment for other services. The CPT Code Manual definition of code A9273 is cold or hot 
fluid bottle, ice cap or collar, heat and/or cold wrap, any type. This code is not paid by Medicare when 
submitted on an outpatient claim. 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 the emergency services provided on 
May 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has multiple medical comorbidities and 
needs care that cannot be provided in a lower-level facility. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 that the enrollees 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires a higher level of rehab services 
to optimize his mobility and strength for his return home. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 that the enrollees 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 IRF admission and services.
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 May 19, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed based 
on the medical records. 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 May 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuroplasty and/or transposition of the ulnar nerve at 
the elbow (64718). 
 
You asked the Plan to pre-approve a neuroplasty and/or transposition of the ulnar nerve. You say that the 
requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested services are 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 a neuroplasty and/or transposition of 
the ulnar nerve. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee is being treated for lesion of the ulnar 
nerve of the left upper limb. Detailed documentation is not evident regarding trial and failure of recent, 
reasonable and comprehensive, less invasive, conservative-care measures for the left elbow. The peer-reviewed 
literature, as noted above, recommends failure of conservative treatments prior to surgery in mild to moderate 
cases of cubital tunnel syndrome. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 
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 neuroplasty and/or transposition of the ulnar nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a neuroplasty and/or transposition of the 
ulnar nerve at the elbow (64718).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is being treated for spondylosis without myelopathy or 
radiculopathy. There are multiple plausible pathologic sources of significant pain generation. 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. The available 
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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. The Plan denied your request. The Plan says three 
additional PT visits are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee is able to do a home exercise program, had 
reached functional independence, and has a chronic condition which requires repetitive exercise to maintain. 
The unique input of a skilled therapist is no longer necessary as the enrollee has an effective therapeutic 
program established and can progress or maintain with a home exercise program. Our reviewer also found that 
the additional visits are 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 the additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve three additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0087U) billed for date of service February 
16, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you have provided records to support the service 
billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that all MDT services must include an identifier as 
additional claim documentation. 
 
 
  We looked at the file and Medicare rules. In this case, the claim for the services at issue was not submitted with 
a unique test identifier. Based on this information, we decided that Medicare rules for coverage of genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0087U) 
billed for date of service February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoe heel wedge (L3350) purchased June 2, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that you are appealing this denial because you are having 
a hard time in physical therapy and still not walking correctly. Your doctor stated you need this to help you 
walk. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the shoe heel wedge (L3350) purchased 
June 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for iron binding test (83550) billed for date of service June 26, 
2018. Neither does the Plan have to pay for laboratory testing (82306, 82607, 82728, 83036, 83540, 84153, 
84466) provided on date of service June 26, 2018. 
 You asked the Plan to pay for iron binding test and laboratory testing. You say that you have provided records 
to support the services billed. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
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 83550 
is a column II code to column I code 84466 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 iron binding test (83550) billed for date of service June 26, 2018. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that an appeal for laboratory testing was not filed until July 12, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for laboratory testing (82306, 82607, 82728, 83036, 83540, 84153, 84466) 
provided on date of service June 26, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intermittent limb compression device. 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that you meet the condition 
required because you have chronic venous insufficiency and a venous stasis ulcer. The Plan denied your 
request. The Plan says you have not successfully completed a supervised lymphedema self-management 
program. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 intermittent limb compression device. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the provided 
records do not adequately document a four-week trial of conservative therapy demonstrating failed response to 
treatment as required. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve intermittent limb compression device.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the left shoulder (73221). 
 
You asked the Plan to pre-approve an MRI of the left shoulder. You say that the enrollee needs the MRI for 
further investigation to see the structural damage to their shoulder. The Plan denied your request. The Plan says 
that the enrollee does not meet the guideline requirements for an MRI of the left shoulder. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the left shoulder. Our 
reviewer says that an MRI of the left shoulder is reasonable and necessary for the enrollee. Our physician 
reviewer found the orthopedic exam revealed positive Hawkins and Neer tests which are highly suspicious for 
rotator cuff pathology. It appears the enrollee has undergone 3 months of home exercises at the direction of a 
physical therapist without success. Our reviewer found that the enrollee qualifies for the requested MRI of the 
left shoulder. 
 
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 MRI of the left shoulder have been met. Therefore, we decided that the Plan 
has to pre-approve a magnetic resonance imaging (MRI) of the left shoulder (73221).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the unlisted molecular pathology, target genomic sequencing 
(81479) provided April 2, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are seeking coverage for biomarker 
testing services provided to the enrollee. The Plan denied your request. The Plan says this test is considered 
experimental and investigational and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for  the unlisted molecular pathology, target genomic sequencing (81479) provided April 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service July 28, 
2022. 
 
You asked the Plan to pay for procedure code 99222. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99222 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 99222 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99222 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99222 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99222 billed for date of service July 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy services provided on July 21, 2022. 
 
You asked the Plan to pay for the services provided. You say that the service was not a duplicate. The Plan 
denied your request. The Plan says the service was billed with an inappropriate place of service. 
 
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 the service at issue was billed with an office place of service setting, 11. The records show that the 
enrollee received care in an outpatient hospital setting. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for the colonoscopy services provided on July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous positive airway pressure (CPAP) device provided on 
February 2, 2022. 
 
You asked the Plan to pay for CPAP device. You say that you included modifier -KX on the original claim 
form. The Plan denied your request. The Plan says that the denial of payment for this item is correct, because 
this claim does not include the -KX modifier and a corrected claim must be submitted. 
 
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. The Plan did not submit a copy of the original claim form submitted. While the 
Plan did submit their internal electronic claim form, you state that you submitted a claim form CMS 1500 
which includes the modifier -KX. Without a copy of the original claim form that you submitted, we cannot 
determine whether this claim was billed in accordance with Medicare guidelines. Therefore, the Plan has not 
shown that its decision to deny payment for this device is correct or justified according to billing and coding 
rules. Therefore, we decided that the Plan has to pay for a continuous positive airway pressure (CPAP) device 
provided on February 2, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service July 30, 
2021, to August 1, 2021. 
 
You asked the Plan to pay for procedure code 99497. You say that the primary code was billed with a modifier. 
The Plan denied your request. The Plan says a proper modifier was not submitted. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
In this case, we have confirmed that code 99497 is a column II code to column I code 99220. 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 99497 
billed for date of service July 30, 2021, to August 1, 2021.