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

 
We decided that the Plan does not have to pay for codes 75774 and 75736 billed with modifier 59 for date of 
service June 6, 2022. 
 
You asked the Plan to pay for codes 75774-59 and 75736-59. You say that the patient had multiple exams on 
this date of service. The Plan denied your request. The Plan says the medical record does not support the use of 
the 59 modifier to allow for separate payment of these codes. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 codes 75774-59 and 75736-59 Our reviewer 
says that the use of the 59 modifier for codes 75774 and 75736 is not supported in the medical record. Our 
physician reviewer found for code 75774, the operative report documents Using the 2 French microcatheter 
selective catheterization of the internal to dental artery was performed an angiogram was obtained... The main 
trunk of the internal pudendal artery was then embolized using 3 mm x 4 cm coils followed by Gelfoam slurry.  In this case, an intervention was performed, which includes radiological interpretation. Therefore, 
modifier -59 cannot be verified. For code 75736, the operative report documents " Using the Omni Flush 
catheter pelvic angiogram was obtained was obtained which demonstrates extremel calcification tortuous 
irregular arteries involving bilateral common iliac artery and hypogastric artery and its branches... The main 
trunk of the internal pudendal artery was then embolized using 3 mm x 4 cm coils followed by Gelfoam 
slurry... The pelvic angiogram was repeated which confirmed with no significant supply to the bladder tumor. 
In this case, the documentation describes an angiogram was performed, with intervention. Interventions include 
radiological interpretation, and therefore modifier -59 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 75774-59 and 75736-59 have not been met. Therefore, we decided that 
the Plan does not have to pay for codes 75774 and 75736 billed with modifier 59 for date of service June 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that this 
service is medically necessary. The Plan denied your request. The Plan says you do not require insulin three or 
more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the 
therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an extremity vein study (ultrasound) 
provided on August 1, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the procedure should 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 a $135 
copayment for radiological diagnostic services, not including x-rays.  
 
You have been asked to pay $132.68, which is less than the $135 copayment for the ultrasound. This 
item/service falls within the radiological diagnostic services, not including x-rays 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 an extremity vein study (ultrasound) provided on August 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee has severe pain in their lower back 
that radiates through their legs. You also say that their pain prevents them from being able to perform daily 
activities. The Plan denied your request. The Plan says a repeat ESI is not 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 the injection. Our physician reviewer 
found the LCD requires three (3) months of 50% pain relief after each ESI. This was not achieved and 
therefore, the request is deemed not medically necessary and reasonable. 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 
injection have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), 
anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar 
or sacral, single level (64483).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that your medical conditions are stable, and you do not have complex medical care 
that requires physician oversight three times per week. 
 
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 you do not have complex nursing or rehabilitation needs. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve injection for sacroiliac joint (CPT code 64451). 
 
You asked the Plan to pre-approve the injection. You say that the injection is medically necessary. The Plan 
denied your request. The Plan says that the requested injection is not medically necessary. 
 
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 the injection. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the request is medically reasonable and necessary and meets the criteria of the LCD. 
 
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 injection have been met. Therefore, we decided that the Plan has to pre-
approve injection for sacroiliac joint (CPT code 64451).  
 
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 pay for limited oral evaluation-problem focused (D0140) provided 
on September 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the requested service paid for by 
the Plan. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested limited oral evaluation-problem focused was exhausted on date of service 
June 22, 2022. The documents show you had this service on October 25, 2021 and June 22, 2022. Therefore, 
we decided that the Plan does not have to pay for limited oral evaluation-problem focused (D0140) provided on 
September 13, 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 28, 2022, 
to March 29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted an NOA, so this 
claim should be paid. 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 28, 2022, to 
March 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 25, 2022, to 
February 22, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you were not aware that there 
was a change to billing practices, so this claim should be reconsidered. 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 January 25, 2022, to 
February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 January 17, 2022.
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 the enrollee needs extensive physical therapy to 
regain strength to be able to care for herself. The Plan denied your request. The Plan says according to the 
clinical documentation, the needed therapy can continue at a lower level of care such as 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for sepsis and pneumonia. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that the enrollee 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 11, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography angiography (CTA) services. 
 
You asked the Plan to pre-approve the CTA scan. You say that the requested CT scan is medically necessary. 
The Plan denied your request. The Plan says that the criteria for coverage of a CT scan have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CTA scan. Our reviewer says that 
the criteria for coverage have been met. Our physician reviewer found the enrollee has known atherosclerosis 
of the aorta and the question of peripheral vascular disease has been raised.  This is what prompted the ankle 
brachial index (ABI) ultrasound test on November 11, 2022, which revealed non-compressible arteries lower 
extremities.  The enrollee has numbness and tingling both feet and lower extremity swelling.  Based upon all 
these factors and the predisposition of peripheral vascular disease the request for CTA and runoff is reasonable 
and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CTA scan have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography angiography (CTA) services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic CGM supplies. 
 
You asked the Plan to pre-approve CGM supplies. You say that you are almost out of supplies and need more. 
The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections and do not require frequent self-adjustment of insulin dosage based on the blood glucose 
testing results. Based on this information, we decided that Medicare rules for coverage of CGM supplies have 
not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic CGM supplies.
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 August 1, 2022, billed with code 99153. 
 You asked the Plan to pay for procedure code 99153. You say that you would like the Plan to reconsider their 
denial of payment. 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 August 1, 2022, billed 
with code 99153.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of the Optimizer Smart implantable pulse 
generator for cardiac contractility modulation (CCM). 
 
You asked the Plan to pre-approve the CCM device placement. You say that you feel that this should be 
approved. The Plan denied your request. The Plan says there is not enough evidence to support medical 
necessity for this device. 
 
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 CCM device placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found An exhaustive review of the current medical literature pertaining to the 
CCM system confirms multiple observational studies suggesting clinical benefit from CCM. Several 
randomized clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the 
data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores and 
objective functional capacity. 
 While the clinical studies led to Food and Drug Administration (FDA) approval in 2019, CCM remains the 
subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. As such, this is considered experimental at the current time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CCM device placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the placement of the Optimizer Smart implantable pulse generator for 
cardiac contractility modulation (CCM).