Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0168 billed for date of service September 
20, 2022. 
 You asked the Plan to pay for procedure code G0168. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code G0168 is bundled into payment for code 12001. 
 
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 G0168 
is a column II code to column I code 12001. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code G0168 billed for date of service September 20, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 99223, 99233, and 99239 billed for date of service 
July 9, 2022, to July 11, 2022. 
 
You asked the Plan to pay for procedure codes 99223, 99233, and 99239. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says that the services were billed with an incorrect place 
of 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. Review of the file shows that the services were billed with place of service 21 
(inpatient hospital). The Plan states that the only authorization on file for this date of service range is for 
Observation. The rule used by the Plan states "If the place of service is valid but inconsistent or incompatible 
with the procedure billed (e.g., the place of service is inpatient hospital and the procedure code billed is office 
visit), then return services as unprocessable since the MAC typically will not know whether the procedure code 
or the place of service is incorrect in such instances". Codes 99223, 99233, and 99239 can be both for hospital 
inpatient services or observation services. Although there may have only been an authorization on file for 
observation, this Medicare rule does not explain why this claim cannot be paid as billed based on the place of 
service billed. Therefore, the Plan's argument regarding the wrong place of service billed is invalid. Therefore, 
we decided that the Plan has to pay for procedure codes 99223, 99233, and 99239 billed for date of service July 
9, 2022, to July 11, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Orthovisc injection. 
 
You asked the Plan to pre-approve an Orthovisc 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 various Hyaluronan preparations 
(viscosupplementation) for intra-articular injections of the knee are considered reasonable and necessary 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 an Orthovisc injection. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the lack of documentation 
precludes repeating this injection. It 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 an Orthovisc injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Orthovisc injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 that you have not tried and failed the 
Plan's required drug, intravenous (IV) bisphosphonate therapy. The records do not show that the required drug 
would have adverse affects or be less effective; therefore, Prolia is 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 Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel One injections. 
 You asked the Plan to pre-approve the Gel one injections. You say that viscosupplementation is needed for this 
enrollee's condition. The Plan denied your request. The Plan says the other preferred agents can be safely tried. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel one injections. Our reviewer 
says that the requested viscosupplement is not reasonable and necessary based on step therapy rules. Our 
physician reviewer found the enrollee has a diagnosis of Unilateral primary osteoarthritis of the left knee. The 
Plan requires a trial of drug Euflexxa, Durolane, Supartz, and Gelsyn-3 before they will approve the requested 
drug. The case file does not contain documentation of trial and failure of Euflexxa, Durolane, Supartz, and 
Gelsyn-3. The documentation does not support that Euflexxa, Durolane, Supartz, and Gelsyn-3 would likely be 
less effective, and/or would likely have adverse effects for the enrollee 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 the Gel one injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Gel One injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 
13, 2022. 
 You asked the Plan to pay for procedure code 76705. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 13, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglass frames provided on July 6, 2022.  
You asked the Plan to pay for eyeglass frames. You say that you need a good pair of eyeglasses and needs to be 
reimbursed. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 when provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of eyeglass frames have not been met. Therefore, we 
decided that the Plan does not have to pay for eyeglass frames provided on July 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36247 and 37253 rendered on November 
17, 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 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 the denied codes is: 
 
CPT 36247: 
 
Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower 
extremity artery branch, within a vascular family 
 
 
 CPT 37253: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; each additional noncoronary vessel (List separately in 
addition to code for primary procedure) 
 
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 documentation does not 
support coverage of the codes in question. CPT 36247 codes for third order selective catheterization. This work 
is included in the code for tibial atherectomy that has already been billed and covered. CPT 37253 codes for 
supervision and interpretation of intravascular ultrasound (IVUS) images of an additional artery. The operative 
note does not include sufficient description of the IVUS findings to justify use of this code. 
 
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 procedure codes 36247 and 37253 rendered on November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code E1399. 
 
You asked the Plan to pre-approve the compression stockings. You say that the requested stockings are 
medically necessary and will stop you from having an operation on your legs. The Plan denied your request. 
The Plan says the requested stocking does not meet the definition of a surgical dressing. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code E1399 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code E1399.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoe inserts from an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are diabetic and need the inserts due to 
calluses on your feet that result in sores. The Plan denied your request. The Plan says the services are available 
from network providers. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
shoe inserts from an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided 
on October 17, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the items rendered are not a covered benefit in 
this place of service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device and appliance was used in an ambulatory surgical center. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliance 
provided on October 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
13, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the code was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 13, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 25, 2022, to 
September 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is not payable as billed.  
The Plan follows Medicare rules. The rules say that an a valid FIPS code must be submitted on home health 
claims. 
 
We reviewed the file and the Medicare rules. We find that the claim was submitted with an invalid FIPS code. 
Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from August 
25, 2022, to September 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on June 21, 2021 to July 20, 
2021. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 the home health services have been 
met. No plan of care or clinical documentation was provided to support the home health episodes billed. 
Therefore, we decided that the Plan does not have to pay for home health services provided on June 21, 2021 to 
July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an artificial cervical disc and cervical fusion. 
 
You asked the Plan to pre-approve an artificial cervical disc and cervical fusion. 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 an artificial cervical disc and cervical 
fusion. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found artificial disc replacement spine surgery is experimental 
when combined with fusion. Long term outcomes and complications remain unknown. 
 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 artificial cervical disc and cervical fusion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an artificial cervical disc and cervical fusion.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiomyopathy risk panel (81400, 81406, 81405, 81404, 
81403, 81161) provided on January 27, 2022. 
 
You asked the Plan to pay for the cardiomyopathy risk panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says screening asymptomatic enrollees for cardiovascular 
risk in not covered. Additionally, panels should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the cardiomyopathy risk panel have not 
been met. Therefore, we decided that the Plan does not have to pay for the cardiomyopathy risk panel (81400, 
81406, 81405, 81404, 81403, 81161) provided on January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 14-day Sensor. You say that you need this sensor. The 
Plan denied your request. The Plan says you do not require insulin three or more times daily. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the Freestyle 
Libre 14-day Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14-day Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88271, 88275) provided on September 9, 
2022. 
 
You asked the Plan to pay for the pathology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 the pathology services have been met. 
Complete clinical records were not submitted to show that coverage criteria was met. Only one page of records 
was provided. Therefore, we decided that the Plan does not have to pay for pathology services (88271, 88275) 
provided on September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of a neurostimulator. 
 You asked the Plan to pre-approve percutaneous implantation of a neurostimulator. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous implantation of a neurostimulator is 
only covered for certain indications. 
 
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 percutaneous implantation of a 
neurostimulator. Our reviewer says that the documentation does not support that the requested services are 
medically reasonable or necessary. Our physician reviewer found the enrollee was being treated for 
lumbosacral root disorders. Conservative treatment included home exercises, injections, a spinal cord 
stimulator, and medications. Formal diagnostic testing for the lumbar spine was not provided. detailed 
documentation is not evident regarding a psychological having been performed. Additionally, the treatment 
request is not consistent with a late and/or last resort. He has a spinal cord stimulator already implanted. No 
compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the enrollee does not meet criteria for the requested 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 percutaneous implantation of a neurostimulator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve percutaneous implantation of a neurostimulator.