Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for code 36246-59 billed for date of service February 1, 2022. 
 
You asked the Plan to pay for code 36246-59. You say that the use of the -59 modifier is valid. The Plan denied 
your request. The Plan says that modifier -59 used for Code 36246 is not supported in the medical record. " The 
operative report shows there was only one catheter placement access site in the right common femoral artery 
which is included in the primary revascularization code submitted. 
 
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 code 36246-59 Our reviewer says that the 
use of the -59 modifier is appropriate in this case, allowing for separate reimbursement of code 36246. Our 
physician reviewer found the use of modifier 59 is appropriate due to a different second-level vessel family 
being accessed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 36246-59 have been met. Therefore, we decided that the Plan has to pay 
for code 36246-59 billed for date of service February 1, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004) provided on April 13, 2022. 
 
You asked the Plan to pay for the eye exam. You say that you have recently been diagnosed with glaucoma, 
and need new glasses. The Plan denied your request. The Plan says your vision benefit has been met for the 
year. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once per year. 
 
We looked at the file and the Plan's rules. The record shows that you received an eye exam on April 13, 2022, 
which the Plan paid $40 for, exhausting this benefit. Based on this information, we decided that the Plan's rules 
for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for 
the eye exam (92004) provided on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 10, 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 services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 4, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there are no 
authenticated medical records from the ordering provider documenting the treating physician had intended the 
clinical diagnostic test be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain medical records 
showing the ordering physicians intent that the testing be performed. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis and the lower extremity extension provided 
on May 11, 2022. 
 
You asked the Plan to pay for the hip orthosis and the lower extremity extension. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the need for the items rendered is not 
supported by the documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the documentation submitted did not sufficiently support the need for 
the billed supply codes. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the hip orthosis 
and the lower extremity extension provided on May 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20937 billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for procedure code 20937. You say that this code is supported in the medical record. 
The Plan denied your request. The Plan says procedure code 20937 is not supported in the medical record. The 
other codes billed have been paid, so this is the only code in dispute. 
 
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 20937 is Autograft for spine surgery only (includes 
harvesting the graft); morselized (through separate skin or fascial incision). 
 
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 procedure code 20937. Our reviewer says that procedure 
code 20937 is not supported in the medical record. Our reviewer found the operative report does not describe per NCCI Policy "The physician makes an incision over the ilium, fibula, or other site from which the autograft 
will be obtained. Fascia and muscles are incised and retracted. A knife, chisel, cutter, or saw may be used to 
obtain the autograft, which will be prepared as needed for implantation in the spine".  Instead, the operative 
report documents "I decorticated the posterolateral arthrodesis from L4-S1 with a Midas Rex burr and also 
decorticated the superficial and dorsal aspect of both SI joints for SI joints fusion utilizing a Midas Rex burr. I 
then placed morselized bone graft harvested from decompression over that area, which only totaled about 
10mL including local autograft from the osteotomies as well as iliac crest bone graft harvest...Additional 
allograft had to be utilized about 75mL, Cellular allograft Osteocel 10mL and low-dose BMP one medium 
packet posterolaterally L4 through S1 including SI joint fusion with bone grafting".  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 20937 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 20937 billed for date of service February 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve Ondansetron tablets. You say that the enrollee has had severe nausea since 
August 21, 2022. The Plan denied your request. The Plan says this medication falls under Part D coverage, but 
the enrollee has no Part D pharmacy benefit. The Plan also says that this medication does not fall under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron tablets.  
 
Benefits for Ondansetron tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 17, 
2022, to March 22, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay was medically 
necessary at the acute level of care. The Plan denied your request. The Plan says the enrollee did not meet the 
inpatient criteria. The Plan also says that the enrollee was hemodynamically stable the entire stay, and had no 
other symptoms to warrant inpatient admission. 
 
 
 
 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 pay for 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 based on the low complexity and low severity of the case and stable neurological and 
medical status, it was not expected that the enrollee would require hospital services that would likely cross 2 
midnights. 
 
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 pay for the acute inpatient hospital care provided from March 17, 2022, to March 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not 
document the billed test as ordered. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain medical records 
showing the ordering physicians intent that the requested testing be performed. 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 the drug testing services provided on February 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve morphine/fentanyl/bupivacaine. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has post-laminectomy 
syndrome. The medications are being requested for administration with an intrathecal pump. The Food and 
Drug Administration (FDA) has not stated that the requested drug combination and administration route is 
indicated for the enrollee's condition. The Food and Drug Administration (FDA) has not stated that the 
requested drug combination and administration route is indicated for the enrollee's condition. The services are 
therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve morphine/fentanyl/bupivacaine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary at this time as it 
would not be clinically advantageous. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT), thorax, diagnostic (71250). 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee needs this service. The Plan denied 
your request. The Plan says that the requested CT scan is not medically necessary. 
 
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 CT scan. Our reviewer says that the 
requested CT is medically necessary. Our physician reviewer found CT of the thorax is a reasonable next step 
for evaluation based upon the abnormal findings on both the CT of the abdomen and the chest x-ray. Therefore, 
the reviewer found that the requested CT is 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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT), thorax, diagnostic (71250).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service  
May 20, 2022. 
 
You asked the Plan to pay for procedure code 99140. The Plan denied your request. The Plan says procedure 
code 99140 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service May 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital for excisional debridement of a left groin/perineum wound with flap reconstruction. 
The enrollee continues to receive acute care services and these have not been denied. The medical record does 
not indicate that the enrollee requires services that she is not currently receiving but that would be available at 
the LTACH facility. The LTACH services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve translumbar interbody fusion surgery. 
 
You asked the Plan to pre-approve translumbar interbody fusion surgery. 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 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 translumbar interbody fusion surgery. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has multilevel lumbar degenerative disc disease without 
instbaility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of translumbar interbody fusion surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve translumbar interbody fusion surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Botox is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has migraine headache 
with aura. The record indicates she has seven to eight headaches monthly. The records do not establish that 
Botox is reasonable and medically necessary for the enrollee, as the criteria for coverage are not met. 
 
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 Botox.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided September 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says you are not a licensed Medicare eligible provider. 
 
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 is not a Medicare eligible provider. 
 
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 the lab 
services provided September 29, 2021.