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

 
We decided that the Plan does not have to pre-approve a prostate rectal spacer (55874). 
 
You asked the Plan to pre-approve a prostate rectal spacer. You say that the service is not medically necessary. 
The Plan denied your request. The Plan says the service is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Polyethylene-glycol (PEG) hydrogel is covered once 
in patients with clinically localized prostate cancer with a low or favorable intermediate prostate cancer risk 
group. 
 
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 prostate rectal spacer. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee has high risk 
prostate cancer. 
 
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 prostate rectal spacer have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a prostate rectal spacer (55874).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 33519-AS and 33533-AS provided on November 18, 
2021. 
 
You asked the Plan to pay for codes 33519-AS and 33533-AS. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT codes 33519-AS and 33533-AS are not supported in the medical record. Specifically, 
Modifier AS is billed to indicate that a PA, NP, or CNS service as the assistant at surgery. Modifier 80, 81, or 
82 must also be billed when modifier AS is billed. This claim was not billed with modifier 80, 81, or 82. This 
means the claim is not payable as billed. Based on this information, we decided that Medicare rules for 
coverage of codes 33519-AS and 33533-AS have not been met. Therefore, we decided that the Plan does not 
have to pay for codes 33519-AS and 33533-AS provided on November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81479) provided on July 19, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this test was recommended by your doctor, and 
you called the Plan to verify your copayment cost. You say you were not told that you would need prior 
authorization for this test. The Plan denied your request. The Plan says there is insufficient information to 
support the medical necessity of this test. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory testing have been met. 
Specifically, the medical records provided do not include a progress note with intent to perform this test or an 
explanation of why this test was medically necessary. It also appears that there is some confusion as to who 
ordered the test, and no physician order was included for review. Therefore, we decided that the Plan does not 
have to pay for laboratory testing (81479) provided on July 19, 2022.  Your complaint about potential misinformation or missing information from the Plan 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care associated with an 
elective right partial mastectomy. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically 
necessary because the enrollee needs to be monitored due to drainage reconstruction. The Plan denied your 
request. The Plan says there is no documentation provided to support the expectation the enrollee will require a 
greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that in this case, the record indicates that the enrollee is scheduled for 
breast lumpectomy and reconstruction. The record provided does not indicate that the treating physician has a 
reasonable expectation of a length of stay spanning 2 or more midnights, taking into account complex medical 
factors. The initial day may be spent in observation until it is clearly expected that a second midnight would be 
required, at which time the physician may order inpatient admission. The elements of the coverage criteria are 
not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care associated with an elective right partial 
mastectomy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64636 billed for date of service August 16, 
2022. 
 
You asked the Plan to pay for procedure code 64636. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 64636 is considered a packaged service. 
 
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 64636 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code 64636 is not payable as billed. Based on this information, we decided that Medicare rules for 
coverage of procedure code 64636 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 64636 billed for date of service August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0105 billed for date of service September 
8, 2022. 
 You asked the Plan to pay for procedure code G0105. 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 G0105 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0105 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0105 billed for date of service September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, G0483) provided on July 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 (80307, G0483) provided on July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64635 x 2, 64636 x 2). 
 
You asked the Plan to pre-approve RFA. You say that the enrollee received 80% relief from the medial branch 
blocks. You also say that the requested injections are medically necessary. The Plan denied your request. The 
Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that initial thermal radiofrequency ablation will be 
considered medically reasonable and necessary after the patient has had at least two (2) medically reasonable 
and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of 
primary (index) pain. 
 
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 RFA. Our reviewer says that the 
requested RFA are not medically necessary. Our physician reviewer found the provided documentation does 
not indicate that the enrollee received the degree of relief from both of the indicated medial branch block 
(MBB) procedures that is required under the guideline. The documentation indicates that the enrollee's pain is 
actually worsened after the second confirmatory injection. Therefore, the reviewer found that the requested 
RFAs are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA) (64635 x 2, 64636 x 2).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 4, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim is billed correctly and should be 
paid. 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 November 4, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injection. 
 
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 epidural steroid injection. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician 
reviewer found in this case; the ESI performed in January 2023 resulted in less than 50% pain relief for only a 
few days. There is no documentation that a new approach or new medications will be used for this repeat 
injection. The review has determined that the enrollee does not meet the LCD criteria for the requested epidural 
steroid injection. 
 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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (ESI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88305) provided on August 22, 2022. 
 
You asked the Plan to pay for pathology services. You say that these services were medically necessary and 
should be covered. The Plan denied your request. The Plan says this provider has opted-out of Medicare and is 
not eligible to receive payment from Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for pathology 
services (88305) provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatments (98941). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the requested 
services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 these services. Our reviewer says that 
the enrollee does not meet criteria for coverage of the requested services. Our physician reviewer found that in 
this case, the record indicates that the enrollee has chronic cervical, thoracic, and lumbar pain, strain, and 
sprain. The record provided does not indicate the presence of a subluxation of the spine.  The record provided is consistent with maintenance therapy. The elements of the coverage criteria are not 
satisfied. The requested services are not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic manipulative treatments (98941).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 1, 2022 to 
October 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that these services were medically 
necessary. 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 October 1, 2022 to 
October 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable gaseous oxygen system (E0431) and oxygen 
concentrator (E1390). 
 
You asked the Plan to pre-approve a portable gaseous oxygen system and oxygen concentrator. You say that 
the items are medically necessary. The Plan denied your request. The Plan says these items are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable gaseous oxygen system and 
oxygen concentrator Our reviewer says that these items are not medically necessary. Our physician reviewer 
found the medical records document pulse oximetry readings of 93% and 94%, presumably breathing room air. 
The medical notes do not mention the need for supplemental oxygen and there is no data on oxygenation 
during exercise. 
 
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 portable gaseous oxygen system and oxygen concentrator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a portable gaseous oxygen system (E0431) 
and oxygen concentrator (E1390).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided June 2, 2022, to July 1, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 2, 2022. The NOA was not received by the Plan until September 21, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided June 2, 2022, to July 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64625). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has 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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records do not show radiographic evidence supporting pathology of the bilateral 
sacroiliac joints. There is no clear history of failure of conservative treatment. 
 
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 an Intracept procedure (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S1015 and S8301 billed for date of service 
October 6, 2022. 
 
You asked the Plan to pay for procedure codes S1015 and S8301. The Plan denied your request. The Plan says 
the billed codes are 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 codes S1015 and S8301 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes S1015 and S8301 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes S1015 and S8301 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes S1015 and S8301 billed for 
date of service October 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from August 
5, 2022, to October 3, 2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. 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 the 30-day period of care is the unit of payment 
for the HH PPS. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the claim at issue has been inappropriately 
billed for a greater than 30-day period of care. Therefore, we decided that the Plan does not have to pay for 
home health services billed for dates of service from August 5, 2022, to October 3, 2022.