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

 
We decided that the Plan does not have to pay for cerebral perfusion analysis using computed tomography with 
contrast administration, including post-processing of parametric maps with determination of cerebral blood 
flow, cerebral blood volume, and mean transit time (code 0042T) provided on June 27, 2022. 
 
You asked the Plan to pay for cerebral perfusion analysis using computed tomography with contrast 
administration, including post-processing of parametric maps with determination of cerebral blood flow, 
cerebral blood volume, and mean transit time. You say that  The Plan denied your request. The Plan says 
cerebral perfusion analysis using computed tomography with contrast administration, including post-processing 
of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time 
does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 cerebral perfusion analysis using computed 
tomography with contrast administration, including post-processing of parametric maps with determination of 
cerebral blood flow, cerebral blood volume, and mean transit time. Our reviewer says that cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric 
maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time was not 
medically necessary in this case. Our physician reviewer found that the enrollee had a headache and neck pain, 
with history of "known brain aneurysms." The record sent by the provider indicates this head CT was 
performed, but there was not CT evidence of regional ischemia or perfusion abnormality. The enrollee did not 
have an acute ischemic stroke due to unilateral large vessel occlusion and was not being evaluated for 
thrombectomy. The review has determined that the cerebral perfusion analysis using computed tomography 
with contrast administration, including post-processing of parametric maps with determination of cerebral 
blood flow, cerebral blood volume, and mean transit time did not meet the Medicare coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cerebral perfusion analysis using computed tomography with contrast 
administration, including post-processing of parametric maps with determination of cerebral blood flow, 
cerebral blood volume, and mean transit time have not been met. Therefore, we decided that the Plan does not 
have to pay for cerebral perfusion analysis using computed tomography with contrast administration, including 
post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and 
mean transit time (code 0042T) provided on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy. 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that endovenous ablation therapy is 
medically necessary. The Plan denied your request. The Plan says endovenous ablation therapy does not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 endovenous ablation therapy. Our 
reviewer says that the requested endovenous ablation therapy is not medically necessary. Our physician 
reviewer found that the enrollee was initially seen in June 2022. At that time, the enrollee presented with very 
mild superficial thrombophlebitis. The enrollee was not using prescription support stockings. There is no documentation that the enrollee was having significant pain from her varicosities. There was no assessment of 
lower extremity arterial perfusion. The provider recommended a four-month course of conservative therapy 
using prescription support stockings. The enrollee returned in October 2022 where it was documented she was 
not using prescription support stockings. Again, there was no mention of significant symptoms and no 
assessment of arterial perfusion to the lower extremities. Coverage criteria require that the enrollee has 
significant symptoms attributable to the veins to be treated that persist despite efforts at conservative treatment 
including the use of compression stockings. These criteria have not been met as it is not documented that the 
enrollee is having significant symptoms. It is documented that the enrollee has not trialed the compression 
stockings that were prescribed. It is not possible to attribute lower extremity symptoms to varicose veins 
without an assessment of lower extremity arterial perfusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for open treatment of femoral shaft fracture provided to the 
enrollee on April 7, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the code cannot be verified. 
 
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, the CPT Code Manual definition of code 27506 is "Open treatment of femoral shaft fracture, with 
or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking 
screws." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee was being treated for 
periprosthetic fracture around internal prosthetic left hip joint. She underwent an open reduction and internal 
fixation of left periprosthetic femur fracture; revision of femoral side of left total hip replacement; femoral stem revision on 4/7/22. The procedure details that the fracture was then reduced anatomically and placed two cables 
above and below the lesser troch around the fracture, getting good anatomic reduction. However, there is no 
clear documentation of intramedullary implant being utilized in this procedure. Therefore, the records do not 
support that CPT 27506 was a separate and distinct procedure from CPT 27318: revision of total hip 
arthroplasty, femoral component only, with or without allograft. 
 
We looked at this coder'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 pay for open treatment of femoral shaft fracture provided to the enrollee on April 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit, an ultrasound, abdominal 
and a radiologic examination, chest; 2 views provided on March 18, 2021. 
 
You asked the Plan to pay for an emergency department visit, an ultrasound, abdominal and a radiologic 
examination, chest; 2 views. You say that you billed the initial claim on May 11, 2021 and the Plan does not 
have that on file so proof of timely filing is attached. The Plan denied your request. The Plan says the claim 
was received on June 14, 2022 by the Plan and by the IPA on May 18, 2022. Both received dates are past the 
allowed 12-month timeframe. 
 
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 a claim for an emergency department visit, an ultrasound, abdominal and a radiologic 
examination, chest; 2 views was not filed until June 14, 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 an emergency department visit, an ultrasound, abdominal and a radiologic examination, chest; 2 
views provided on March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for rigid panel lower back brace provided on 
June 1, 2022. 
 
You asked the Plan to waive the coinsurance for rigid panel lower back brace. You say that you are disputing 
the share cost. 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 20% 
coinsurance for durable medical equipment and related supplies. The allowed amount of this brace total 
$1,288.57, resulting in a coinsurance amount of $257.71. 
 
You have been asked to pay 20% coinsurance for rigid panel lower back brace. This item/service falls within 
the durable medical equipment and related supplies 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 
coinsurance for rigid panel lower back brace provided on June 1, 2022.   
Your complaint about cannot bring the brace back to the office is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a new implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of a new ILR. 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 follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve placement of a new ILR. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for 
an ILR. In summary, there is insufficient documentation to support the medical necessity for insertion of an 
ILR in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of a new ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a new implantable loop recorder (ILR).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) provided on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 item or service was exhausted on date of service February 1, 2022. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0150) provided on August 8, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 20, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that transportation was not necessary. The Plan 
denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on April 20, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax/shipping (S9999) from March 5, 2022. 
 
You asked the Plan to pay for procedure code S9999. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9999 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9999 is not valid for Medicare purposes. Medicare does not cover sales tax or shipping. Based 
on this information, we decided that Medicare rules for coverage of procedure code S9999 have not been met. 
Therefore, we decided that the Plan does not have to pay for sales tax/shipping (S9999) from March 5, 2022.
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 16, 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 16, 2022, billed with 
code 99153.
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 to be in an IRF with more 
adequate therapy to help her walk again. You say the enrollee is determined to walk again. The Plan denied 
your request. The Plan says the documentation provided does not indicate that the enrollee meets the criteria 
for an IRF admission. 
 
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services or 
to require regular physician evaluation. The enrollees care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiovascular stress test using maximal or submaximal 
treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with 
supervision, interpretation and report provided to the enrollee on June 16, 2022. 
 
You asked the Plan to pay for the stress test. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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, the CPT Code Manual definition of code 93015 is "Cardiovascular stress test using maximal or 
submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological 
stress; with supervision, interpretation and report." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the stress test. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records show that the enrollee 
underwent a stress test in 2013; however, there is no documentation of a 2022 stress test, or the rationale for its performance. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the stress test have not been met. Therefore, we decided that the Plan does not 
have to pay for a cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, 
continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and 
report provided to the enrollee on June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dentures, intra oral x-rays, and a filling (D2335, D0220, 
D0230, D5226) provided on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit a dental filling (D2335) has already 
been exhausted. Additionally, coverage for the intra oral x-rays and dentures are denied as they do not fall 
within your dental benefits. 
 
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 item or service was exhausted on date of service June 7, 2022. Therefore, 
we decided that the Plan does not have to pay for dentures, intra oral x-rays, and a filling (D2335, D0220, 
D0230, D5226) provided on June 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. 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 August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pin retention (D2951) on tooth number 19 provided on 
August 2, 2022. 
 
You asked the Plan to pay for a pin retention (D2951) on tooth number 19. You say that this is your first 
submitted dental charge in two and a half years. The Plan denied your request. The Plan says a pin retention is 
not a covered benefit under the member's dental plan. 
 
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 pay for a pin 
retention (D2951) on tooth number 19 provided on August 2, 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 you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, your needs can be provided safely in other settings. 
 
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 your 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 acute IRF admission and services.