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

 
We decided that the Plan does not have to pre-approve tertiary level orthopedic surgeon consultation (99204) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient office visit. You say that you have been unable to see the 
approved surgeon because they keep canceling the appointments. This provider confirmed they are in-network, 
yet you received an approval to the same office you are trying to change from. The Plan denied your request. 
The Plan says the records do not support that tertiary level of care is medically necessary. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider at issue in this case is not a network provider with the Plan. 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 outpatient office visit. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found detailed documentation is not evident regarding any significant deficits or unique clinical findings that 
would require more specialized care. The documents provided do not support the need for this level of care or 
that the care being requested could not be provided on a community-based level of care. There is no compelling 
rationale presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested tertiary-level orthopedic surgeon consultation (CPT 99204), in this case, is 
not medically reasonable or necessary and the Plans denial is medically justified on the basis that it is offering 
adequate care to meet the enrollees medical needs through referral to approval to a community-level provider. 
 
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 outpatient office visit have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the outpatient office visit. Therefore, we decided that 
the Plan does not have to pre-approve tertiary level orthopedic surgeon consultation (99204) to be provided by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment codes E0673 and E0675 billed 
for date of service November 30, 2022. 
 
You asked the Plan to pay for the billed services. You say that the device was supplied to the enrollee during 
their procedure. The Plan denied your request. The Plan says the devices are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 
 The items at issue in this appeal were provided in an ambulatory surgical center. Although the services may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pay for durable medical equipment codes E0673 and E0675 billed for date of service 
November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care (99221) provided on March 30, 2022. 
 
You asked the Plan to pay for the observation care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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 code 99221 is not supported in the medical record. Specifically, the records show the 
enrollee was in outpatient observation, however the claim was billed with an inpatient place of service (21). 
Based on this information, we decided that Medicare rules for coverage of the observation care have not been 
met. Therefore, we decided that the Plan does not have to pay for observation care (99221) provided on March 
30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152-59 billed for date of service 
September 15, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code is supported in the documentation. The 
Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
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.   The records provided do not show that the service billed with the -59 modifier was a distinct procedural 
service. Furthermore, there is a more appropriate code available to describe the sedation services provided. 
Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99152-59 
billed for date of service September 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the enrollee has not 
met the required criteria to receive admission to the Skilled Nursing Facility. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation (A0429-RH, A0425-RH) provided on August 
1, 2022. 
 
You asked the Plan to pay for ambulance transportation. You say that the enrollee was not admitted to the 
hospital until the day after these services were provided, and therefore these services are separately payable. 
The Plan denied your request. The Plan says that these services were inappropriately coded, as the payment for 
these services is included in the hospital payment. 
 
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 any evidence to show that the enrollee as 
already admitted as inpatient status to any facility on the date in question. In addition, these services were 
coded with origin/destination modifier RH, indicating that the enrollee was transported from their residence to 
a hospital setting. This is supported by the medical records provided. Therefore, the Plan's denial is not 
substantiated in this case as these services would be separately payable. Therefore, we decided that the Plan has 
to pay for ambulance transportation (A0429-RH, A0425-RH) provided on August 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient psychiatric hospitalization provided on 
October 24, 2022, to November 14, 2022. 
 
You asked the Plan to pay for acute inpatient psychiatric hospitalization. You say that this inpatient stay was 
medically necessary. The Plan denied your request. The Plan says the enrollee could have been treated in a less 
restrictive facility. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric hospitalization. 
Our reviewer says that an acute inpatient psychiatric hospitalization was not medically necessary. Our 
physician reviewer found from November 3, 2022, forward claiming that this enrollee did not meet the level of 
care criteria for an acute inpatient psychiatric hospitalization but could have been treated in a lesser restrictive 
setting. 
 
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 psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pay for acute inpatient psychiatric hospitalization provided on October 
24, 2022, to November 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services for a shoulder arthroplasty 
procedure (23472) provided on September 27, 2022. 
 
You asked the Plan to pay for surgical assistant services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for surgical assistant 
services have not been met. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services for a 
shoulder arthroplasty procedure (23472) provided on September 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. If the enrollee did have chronic carbon dioxide (CO2) retention, bilevel positive airway pressure 
(BiPAP) with average volume-assured pressure support (AVAPS) may be of benefit. Medicare does not cover 
a home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophageal balloon distension (EndoFlip) study. 
 
You asked the Plan to pre-approve an EndoFlip study. You say that the records provided support the need for 
the service in dispute. The Plan denied your request. The Plan says the requested procedure is considered 
investigational. 
 
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 EndoFlip study. Our reviewer says 
that the requested EndoFlip study is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the standard of care for achalasia management depends on manometric subtype. 
While EndoFlip may provide complementary information regarding the mechanics of the esophagus and help 
treatment options, EndoFlip is not a substitute for high resolution manometry. The available records do not support that a high resolution manometric study has yet been performed. The records do not support that 
EndoFlip is medically necessary or appropriate for the enrollee at this stage in her treatment planning. 
 
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 EndoFlip study have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an esophageal balloon distension (EndoFlip) study.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care because you live alone, and you 
do not have anyone to help you. The Plan denied your request. The Plan says you do not meet the Medicare 
criteria for admission to an IRF. The services you need can be provided at a skilled nursing facility (SNF), 
home with home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. 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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion 
interspinous spacer at L3-4, in this case, is 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this item is experimental. 
 
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 a MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro is not the standard of care for this patient's condition or in widespread use for this 
patient's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long term outcomes for this patient or  that this device will increase participation in 
bimanual activities.  
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third level injection of lower or sacral spine facet joint 
(64495). 
 
You asked the Plan to pre-approve a third level injection. 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 follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered 
under unique circumstances and with sufficient documentation of medical necessity on appeal. 
 
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 third level injection. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the LCD utilization limits the 
diagnostic blocks to 2 levels, so a third level 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 a third level injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a third level injection of lower or sacral spine facet joint (64495).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0482 provided on August 30, 2022. 
 
You asked the Plan to pay for procedure code G0482. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the records do not support the services 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0482 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records show that 21 drug 
classes were tested, including Alcohol, Amphetamines, Antidepressants-tricyclic and other cyclicals, 
Benzodiazepines, Buprenorphine, Cannabinoids-natural, Cannabinoids-synthetic, Cocaine, Fentanyls, Heroin 
metabolite, Ketamine and Norketamine, Methadone, Methylenedioxyamphetamines, Opiates, Opioids and 
opiate analogs, Oxycodone, Phencyclidine, Propoxyphene, Skeletal muscle relaxants, Tapentadol, and 
Tramadol. Based on this information, we decided that Medicare rules for coverage of procedure code G0482 
have been met. Therefore, we decided that the Plan has to pay for procedure code G0482 provided on August 
30, 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.