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

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept Procedure. You say that the procedure is medically necessary. 
The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered 
by Medicare. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental and investigational. There is more research 
needed to show safety and efficacy. 
 
 
 
 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 thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in iVAPS mode with Auto-EPAP 
(AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that in this 
case, the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary 
disease. The provided primary source documentation does not contain sufficient detailed information in the 
medical record to justify the treatment selected. The enrollee could be treated with a bilateral positive airway pressure (BiPAP) machine with average volume-assured pressure support (AVAPS) capability. The plan has 
indicated coverage for such a device is available upon request. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a black 4-wheel walker with seat (E1399). 
 
You asked the Plan to pre-approve a walker with seat. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says under the Medicare guidelines a 
walker coded as E1399 is not medically necessary because there is no documentation to support why this code 
(E1399) was used over a Medicare approved code which would justify payment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show you have requested a brand specific, wheel walker 
with seat. For the requested item to be covered, you would need to have medical notes that explain the features 
of this item that distinguish it from other available (preferred) alternatives and a reason why the specific brand 
item requested is necessary to avoid an adverse medical outcome such as new or worsening symptoms, injury, 
or hospitalization. Your records do not show medical notes with this explanation. Based on this information, 
we decided that Medicare rules for coverage of a walker with seat have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a black 4-wheel walker with seat (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Via Disc NP allograft procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this procedure is considered experimental, and therefore not covered. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is little evidence in the medical literature to suggest that this is an appropriate 
procedure for the enrollees back pain. It is not an accepted standard of medical practice for the diagnosis or 
treatment of back pain. The requested injection of allograft (in this case, VIA Disc NP) into the intervertebral 
disc for the treatment of degenerative disc disease, is considered experimental and investigational and not 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Via Disc NP allograft procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services rendered on June 16, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider type is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is made for an assistant at surgery when 
the procedure is authorized for an assistant and the person performing the service is a physician, physician 
assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS). 
 
We looked at the file and Medicare rules. Review of the record shows that the provider is not a physician, PA, 
NP, or CNS. Therefore, we decided that the Plan does not have to pay for the surgical assistant services 
rendered on June 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for open treatment of femoral fracture, proximal end, neck, 
internal fixation or prosthetic replacement provided to the enrollee on May 19, 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 Current Procedural Terminology (CPT) code 27236 remains not supported. 
 
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 27236 is "Open treatment of femoral fracture, proximal 
end, neck, internal fixation or prosthetic replacement." 
 
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 only documentation provided 
for review was the consultation that recommended surgery. There were no operative reports to support that the 
noted code was performed. Therefore, the records do not support that CPT 27236: open treatment of femoral 
fracture, proximal end, neck, internal fixation or prosthetic replacement was rendered in this case.  
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 fracture, proximal end, neck, internal fixation or prosthetic 
replacement provided to the enrollee on May 19, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a new patient office visit (code 99205) and an established patient office 
visit (code 99214) provided from May 4, 2022 to June 29, 2022. 
 
You asked the Plan to pay for the office visits. You say that there was no procedure done on these claims that 
would make them incidental to another service. You say that this provider is not a Radiologist, he is a 
Rheumatologist. The Plan denied your request. The Plan says that this charge is incidental to another service. 
 
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. Specifically, the Plan has not provided a coding rule, a Medicare rule or a Plan 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for a new patient office visit 
(code 99205) and an established patient office visit (code 99214) provided from May 4, 2022 to June 29, 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for removal of ankle implant provided to the enrollee on July 6, 2022. 
 
You asked the Plan to pay for the removal. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied code cannot be verified. 
 
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 the removal Our reviewer says that the 
service at issue in this case is supported by the medical records. Our physician reviewer found that the enrollee 
was being treated for mechanical loosening of internal prosthetic joint. She underwent a right removal of total 
ankle prosthesis, right iliac crest major bone graft, and right ankle arthrodesis on 7/6/22. The procedure details 
cite the polyethylene was removed. Using an osteotome the tibial base plate was further loosened and removed 
from the tibia. The polyethylene was broken and was removed. The talar component was well-fixed. The talar 
component was removed from the talus. There was a plate along the distal medial tibia and the plate and screws 
were removed. The heel screw which was used for a subtalar fusion was also removed. In this case, there was 
noted to be broken polyethylene. The hardware was removed as well as the sclerotic bone. These were 
performed prior to the ankle being reduced, prepared, and performance of the arthrodesis. Therefore, the 
records do support that CPT 27704: removal of ankle implant was a separate and distinct procedure from CPT 
27870: arthrodesis, ankle, open. 
 
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 removal have been met. Therefore, we decided that the Plan has to pay for 
removal of ankle implant provided to the enrollee on July 6, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from September 28, 2022 to 
October 12, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the provider called to make sure that this was 
covered before you started treatment and was told it was covered. The Plan denied your request. The Plan says 
the claims are not payable as the specialty of this provider is a non-payable specialty with CMS. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from September 28, 2022 
to October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the role of genicular nerve blocks and of radiofrequency of the genicular nerves is the subject of 
ongoing clinical trials. It is considered experimental at this time.  Therefore, the request is deemed not 
medically 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 37253. We decided that the Plan does not have to pay 
for procedure code 75710.  
 
You asked the Plan to pay for procedure codes 37253 and 75710 provided on June 29, 2022.. You say that 
these services were medically necessary. The Plan says that the records provided do not support the codes 
billed. 
 
 
 We decided that the Plan has to pay for procedure code 37253.  
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
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 procedure codes 37253. Our reviewer says 
that code 37253 is supported in the records. Our physician reviewer found the medical records do support the 
use of procedure code 37253.  
 
We also decided that the Plan does not have to pay for procedure code 75710. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
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 procedure code 75710. Our reviewer found 
that medical records do not support the use of procedure 75710 because this code is included in procedure code 
37229 as they were performed on the same laterality.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 75710 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 75710. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional trips for routine transportation beyond the 
Plan's 36-trip limit. 
 
You asked the Plan to pre-approve the additional trips for routine transportation. You say that this 
transportation is necessary to get to dialysis appointments. The Plan denied your request. The Plan says the 
requested trips exceed your trip limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 We looked at your request, the records in the case file, and the rules. The Plan provided documentation 
showing that 36 routine transports have already been covered. Based on this information, we decided that you 
have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that 
the Plan does not have to pre-approve the additional trips for routine transportation beyond the Plan's 36-trip 
limit.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99220. We decided that the Plan does not have to pay 
for procedure codes 99217 and 93010.  
 
You asked the Plan to pay for procedure codes 99220, 99217 and 93010 billed for dates of service June 14, 
2022, to June 15, 2022. You say that code 99220 was denied as a duplicate in error and should be paid. The 
Plan says that this claim is a duplicate of a previously paid claim and was correctly denied. 
 The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We decided that the Plan has to pay for procedure code 99220.  
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the record does not include any 
documentation to show that procedure code 99220 was previously paid. No other argument for denial of this 
service was provided. Based on this information, we decided that Medicare rules for coverage of procedure 
code 99220 have been met. Therefore, we decided that the Plan has to pay for procedure code 99220.  
 
We also decided that the Plan does not have to pay for procedure codes 99217 and 93010. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 25, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that Medicare rules for procedure codes 99217 and 93010 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99217 and 93010. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) with quantitative calcium 
scoring. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare does not cover the requested study for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary. 
 
The requested imaging is considered screening and not covered. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) with quantitative calcium scoring.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service from April 
29, 2022, to May 20, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the services at issue have been billed 
correctly. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service from April 29, 2022, to May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 1, 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 September 1, 2022.