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

 
We decided that the Plan does not have to pay for the injection services coded 64450 and billed with -59 
modifier provided on August 24, 2021. 
 
You asked the Plan to pay for the injection services as billed. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says the medical 
documentation does not support the use of the 59 modifier to indicate that the procedure was distinct or 
independent from other services performed. 
 
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 64450 is a column II code to column I code 01402; however, 64450 
was billed with a modifier.  
 
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 injection services as billed. Our reviewer says that the 
documentation does not support the billing of the 59 modifier to bypass the edit. Our reviewer found the 
procedure report does not verify this procedure was distinct from anesthesia services, and performed for post-
operative pain management. Per operative report "Patient location during procedure: Per-op; Reason for block: 
Primary anesthetic in the OR". 
 
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 injection services as billed have not been met. Therefore, we decided that 
the Plan does not have to pay for the injection services coded 64450 and billed with -59 modifier provided on 
August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010) for tooth #12, bone graft at time of implant placement (D6104) for tooth #12, and removal of residual 
tooth roots (D7250) for tooth #12. 
 
You asked the Plan to pre-approve the endosteal implant, bone graft, and removal of residual tooth roots for 
tooth #12. The Plan denied your request. The Plan says the dental records and x-rays do not support these 
services for tooth #12. 
 
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. The Plan covers the endosteal 
implant, bone graft, and removal of residual tooth roots for tooth #12 when the services are medically 
necessary and reasonable.  
 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 endosteal implant, bone graft, and 
removal of residual tooth roots for tooth #12. Our reviewer says that the endosteal implant, bone graft, and 
removal of residual tooth roots are not medically reasonable and necessary for tooth #12. Our physician 
reviewer found the documentation supports the indicated treatment for tooth #13. Our reviewer also found that 
tooth #12 was indicated in error. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the endosteal implant, bone graft, and removal of residual tooth roots for tooth 
#12 have not been met. Therefore, we decided that the Plan does not have to pre-approve a surgical placement 
of implant body: endosteal implant (D6010) for tooth #12, bone graft at time of implant placement (D6104) for 
tooth #12, and removal of residual tooth roots (D7250) for tooth #12.  
 
Please Note: Our physician reviewer found that the documentation that was submitted supports the indicated 
treatment for tooth #13.  Tooth #12 was indicated in error. A resubmission with the correct tooth (#13) would 
be necessary for coverage.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laboratory services provided July 13, 2021. 
 
You asked the Plan to pre-approve the laboratory services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the lab tests are the responsibility of 
the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pre-
approve the laboratory services provided July 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 13, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you were told that this provider was in-network with 
the Plan and you would like to keep seeing this provider. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because this provider is out-of-network with the Plan and 
authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on December 13, 2021 by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the 
enrollee has suffered from this condition for over one year and has failed more than 6 months of conservative 
approaches to treatment. You say that this treatment is safe and effective, and the pre-authorization request 
should be approved. The Plan denied your request. The Plan says there are not enough studies on Vertiflex 
Superion to show it is safe and effective. 
 
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 insertion of stabilization device 
(22869 and 22870). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the record indicates the presence of 20 
degrees scoliosis. The Food and Drug Administration states that the requested procedure is contraindicated if 
the individual has more than 10-degree scoliosis. The elements of the coverage criteria are not satisfied, and the 
requested service cannot be 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 insertion of stabilization device (22869 and 22870) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 
and 22870).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (95886), nerve conduction 
(95913), visual evoked potential (VEP) checkerboard or flash testing (95930), and somatosensory testing 
(95938) provided on September 8, 2021. 
 
You asked the Plan to pay for the needle electromyography, nerve conduction studies, VEP and somatosensory 
testing. You say that you would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says the documentation submitted does not include any authenticated records. 
 
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 needle electromyography (95886), 
nerve conduction (95913), visual evoked potential (VEP) checkerboard or flash testing (95930), and 
somatosensory testing (95938) provided on September 8, 2021. have been met. Specifically, the documentation 
submitted does not include any medical records to verify the services billed. Therefore, we decided that the 
Plan does not have to pay for needle electromyography (95886), nerve conduction (95913), visual evoked 
potential (VEP) checkerboard or flash testing (95930), and somatosensory testing (95938) provided on 
September 8, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
enrollee meets the Medicare criteria for SNF care. Our physician reviewer found based on the medical records 
provided there is documentation that daily skilled services are required. The enrollee is walking less than 
household distances with minimum assistance with a rolling walker and is supervision to minimum assist for 
transfers. There is documentation that the enrollee requires the services on an inpatient basis in a skilled 
nursing facility setting due to a significant decline in the enrollees functional status compared to his recent 
baseline.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that this item is medically necessary. The Plan 
denied your request. The Plan says the requested power wheelchair is more than the allowed limit. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. Specifically, the 
medical records indicate that you are currently ambulating with a cane. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve a power wheelchair. You say that using a PMD will significantly improve 
the enrollee's ability to participate in MRADL's and the enrollee will use the PMD in the home. The Plan 
denied your request. The Plan says the records do not support that the enrollee meets medically necessary 
criteria for the requested group 3 power wheelchair with power options. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the group 3 
power wheelchair with multiple power options at issue in this case meets Medicare criteria for medically 
reasonable and necessary. The records do not document that the enrollee is high risk for skin breakdown, 
requires bladder self-catherization or has increased muscle tone or spasticity to meet criteria for the power tilt 
and recline feature, thus the multiple power options do not meet criteria. A group 3 power wheelchair with no 
power options appears to meet Medicare criteria for coverage in this case. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a group 3 power wheelchair with multiple power options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (E0118). 
 
You asked the Plan to pre-approve the knee scooter. You say that the knee scooter is medically necessary. The 
Plan denied your request. The Plan says this device is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for crutch substitutes (E0118) there is 
insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to 
establish the medical necessity for these products. 
 
We looked at the file and Medicare rules. This device is not covered. Based on this information, we decided 
that Medicare rules for coverage of the knee scooter have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a knee scooter (E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device (E0673), provided on 
July 14, 2021. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device 
(E0673), provided on July 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that these services are contraindicated for the enrollee. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these services. 
 
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 the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 16 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve an additional 16 PT visits. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 additional 16 PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a 
therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
your current condition or to prevent or slow further deterioration. 
 
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 additional 16 PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 16 physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a backup power wheelchair. 
 
You asked the Plan to pre-approve repairs to a backup power wheelchair. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. A power wheelchair serves the same purpose as the backup 
power wheelchair. Since a duplicate DME would not be covered, repairs for a duplicate DME are not covered. 
Therefore, we decided that the Plan does not have to pre-approve repairs to a backup power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from February 22, 2020, 
through February 24, 2020, billed with secondary diagnosis code G92. 
 
You asked the Plan to pay for the inpatient services as billed. You say that this claim was billed correctly. The 
Plan denied your request. The Plan says the secondary diagnosis code is not supported, and the DRG is 
increased by this inappropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code G92, defined as Toxic 
encephalopathy. 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 inpatient services as 
billed. Our reviewer says that the record does not support the use of diagnosis code G92 as a secondary 
diagnosis. Our physician reviewer found the enrollee came to the emergency room on 2/22/2022 with altered 
mental status and slurred speech. He did not remember the duration of symptoms. He also reported that he did 
not have any other focal neurological symptoms or signs. Ten days ago, he had similar symptoms. At that time, 
he did not seek medical attention. Flu panel returns positive for flu with pneumonia, no elevated white count.  
 
At the time of history and physical the examiner noted he was alert and oriented. Advanced imaging of the 
head rules out any neurological abnormalities. In the absence of metabolic derangements and or a toxin the 
code for toxic encephalopathy was not supported, the encephalopathy code G93.49 for encephalopathy in 
diseases classified elsewhere is more appropriate. The review indicates that the documentation does not support 
the reporting of G92 (Toxic encephalopathy) as a secondary diagnosis for this admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care provided from February 22, 2020, through February 24, 2020, billed with 
secondary diagnosis code G92.