Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H0046 billed for date of service January 4, 
2023. 
 
You asked the Plan to pay for procedure code H0046. You say that you have been seeing this patient for over a 
year and these services were medically necessary. The Plan denied your request. The Plan says the billed code 
is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code H0046 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H0046 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H0046 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H0046 billed for date of service January 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service November 
21, 2022. 
 
You asked the Plan to pay for the billed service. You say that the drug screen provides valuable information for 
physicians. The Plan denied your request. The Plan says the testing did not meet the rules for approval. 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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The medical records show that 
the enrollee has not exhibited any signs of problematic behaviors or medication abuse. The medical records do 
not indicate that the testing was ordered due to suspicious behaviors or documented change in affect or 
behavioral pattern.  Based on this information, we decided that Medicare rules for coverage of the billed 
service have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0483 
billed for date of service November 21, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing provided on November 29, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the claim was not 
billed with the appropriate DEX Z-code. 
 
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. The Plan argues that the claim was not billed with the appropriate DEX Z-code. 
However, the submitted claim form shows that the services were billed with DEX Z-code Z004C. The Plan has 
not provided documentation showing that this code is incorrect for the billed services, nor did the Plan show 
which code would be appropriate in this case. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the genetic testing provided on November 29, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the central motor evoked potential study (95928) provided on September 26, 2022.
You asked the Plan to pay for the central motor evoked potential study. You say that you would like the Plan's denial to be overturned. The Plan denied your request. The Plan says charges for or in connection with services or supplies that are, as determined by the Plan, considered to be experimental or investigational are excluded from coverage under the enrollee's plan.
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 pay for the central motor evoked potential study. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee underwent surgery for cervical spinal stenosis. Use of Intraoperative Neuromonitoring (IONM) services in such procedures is generally consistent with the standards of practice/care. Our reviewer found that in this case the current procedural terminology (CPT) code that was submitted does accurately reflect the services provided. The enrollee had motor evoked potentials assessed in the upper and lower extremities. Our physician reviewer also found that in such a setting it would have been more appropriate to code for 95939, and given the improper CPT code, medical necessity cannot be established. 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 central motor evoked potential study have not been met. Therefore, we decided that the Plan does not have to pay for the central motor evoked potential study (95928) provided on September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pacemaker placement (33207, 33208). 
 
You asked the Plan to pre-approve the pacemaker placement. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that pacemaker placement is covered for documented 
non-reversible symptomatic bradycardia due to sinus node dysfunction, and documented non-reversible 
symptomatic bradycardia due to second degree and/or third degree atrioventricular block. 
 
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 pacemaker placement. Our reviewer 
says that the requested procedure is not medically necessary. Our physician reviewer found there is insufficient 
documentation to support the medical necessity for the requested cardiac pacemaker in this patients clinical management. 
 
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 pacemaker placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a pacemaker placement (33207, 33208).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair replacement. 
 
You asked the Plan to pre-approve the wheelchair replacement. You say that the wheelchair is needed due to 
the wear and tear of the current wheelchair. The Plan denied your request. The Plan says the members current 
wheelchair is less than 5 years old. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair replacement have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the wheelchair replacement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77001 billed for date of service June 30, 
2022. 
 You asked the Plan to pay for procedure code 77001. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 77001 is bundled into payment for 
code 36904. 
 
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 77001 
is a column II code to column I code 36904. 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 77001 billed for date of service June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator (FES) (E0770). 
 
  You asked the Plan to pre-approve a functional electrical stimulator. You say that the enrollee has sustained 
neck and head injuries that have left them paralyzed except for some use of their right hand. You also say that 
the enrollee cannot stand or walk on their own, and fits all the necessary criteria for using the requested device. 
The Plan denied your request. The Plan says a functional nerve stimulator is not covered for diagnosis of 
stroke. 
 
The Plan follows Medicare rules. Medicare rules say that coverage for NMES/FES for walking will be covered 
in SCI patients with all of the characteristics listed in the Medicare rules section of this letter. 
 
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 functional electrical stimulator. Our 
reviewer says that a functional electrical stimulator is not medically reasonable and necessary for the enrollee. 
Our physician reviewer found a FES device is only covered for use in individuals who have a history of a 
spinal cord injury (when additional requirements for coverage are met). Our reviewer found that in this case the 
enrollee does not have a history of a spinal cord injury, nor are they otherwise ambulatory. In this setting the 
baseline requirements of the NCD for coverage of the requested item would not be met. Our physician reviewer 
also found that this would not be eligible for coverage. 
 
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 functional electrical stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a functional electrical stimulator (FES) (E0770).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving the appropriate 
level of care and does not require transfer to an LTACH. 
 
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 that the documentation does not support that the enrollee has need for complex 
medical treatment in a LTACH (e.g., multiple and prolonged intravenous therapies, monitoring of significantly 
medically active conditions requiring clinical assessment 6 or more times a day, multiple and frequent 
intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, complex wound 
care for multiple wounds stages 3 and above, the need for specialized high-tech equipment like cardiac 
monitors, on-site dialysis, or surgical suites). The enrollee does not require services at the LTACH that are not 
available at the acute care hospital or the skilled nursing facility. The requested treatments are not medically 
necessary at the LTACH level of care. The enrollee has improved medically and can receive further care at the 
current acute care hospital or a lower level of care when deemed appropriate. 
 
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 the LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 5, 2022, 
to October 4, 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 has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. 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 September 5, 2022, to 
October 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hyoid myotomy and suspension (code 21685) provided 
on date of service October 18, 2022. 
 
You asked the Plan to pay for the hyoid myotomy and suspension. You say that the patient had high instance of 
sleep apnea during their sleep study, so this procedure was warranted. The Plan denied your request. The Plan 
says this service was not medically necessary. There is no evidence of any attempt to treat the patient's 
condition with continuous positive airway pressure. 
 
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 pay for the hyoid myotomy and suspension. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found published clinical guidelines recommend consideration of positive airway 
pressure (PAP) and oral appliance therapy for patients with obstructive sleep apnea (OSA). Surgical procedures 
may be considered as secondary treatment for OSA when the outcome on PAP is inadequate or is not tolerated. 
The case file does not contain documentation of failure of medical management of OSA. The current literature 
lacks high-quality evidence with regard to hyoid surgery, and additional studies are needed to further elucidate 
the effect of hyoid surgery in OSA. The records do not show that the patient has failed positive airway 
pressure, or that a surgically correctable problem was identified. There is no documentation of an examination 
while the patient was asleep. 
 
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 hyoid myotomy and suspension have not been met. Therefore, we decided 
that the Plan does not have to pay for the hyoid myotomy and suspension (code 21685) provided on date of 
service October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 10, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says 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 Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Transcutaneous electrical nerve stimulation (TENS) device 
(E0730) provided on November 9, 2022. 
 
You asked the Plan to pay for the TENS device. You say that this device was medically necessary. The Plan 
denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claim lines billed for E0720, E0730, and E0731 
without a GA, GZ or KX modifier as specified above will be rejected as missing information. 
 
We looked at the file and Medicare rules. The claim was not billed with a required modifier. Based on this 
information, we decided that Medicare rules for coverage of the TENS device have not been met. Therefore, 
we decided that the Plan does not have to pay for a Transcutaneous electrical nerve stimulation (TENS) device 
(E0730) provided on November 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic 
compressor (E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure 
(E0652). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the enrollee's records do not show the enrollee meets all of the requirements. The 
Plan states the request is not medically necessary because the enrollee does not have swelling of their chest, 
trunk, or abdomen. 
 
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. 
 
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 DME. Our physician reviewer 
found the reviewed documentation for the enrollee's provider describes problems with swelling of the enrollee's 
legs. None of the actual medical records describe swelling of the chest or trunk. The medical records say that 
the enrollee has poor venous circulation and have edema the lower legs. The review has determined that the 
medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve segmental pneumatic appliance for use with pneumatic compressor (E0667) and pneumatic 
compressor, segmental home model with calibrated gradient pressure (E0652).
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the injections provided on May 5, 2022. We also 
decided that the Plan does not have to waive the coinsurance for the upper endoscopy and other medical 
services provided on May 5, 2022.  
 
You asked the Plan to waive the coinsurance for the upper endoscopy, injections, and other medical services. 
You say that you are appealing the coinsurance for claim EQ36Y8GFP00. The Plan says that this cost sharing 
was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the injections provided on May 5, 2022.  
 
You have been asked to pay 15% coinsurance for each injection provided during the upper endoscopy. 
According to Medicare, a propofol Injection (J2704) and a ringers lactate infusion (J7120) are considered 
packaged codes and are not separately payable. These codes are also excluded from the physician's fee 
schedule. Therefore, we decided that the Plan has to waive the coinsurance for the injections provided on May 
5, 2022. 
 
We also decided that the Plan does not have to waive the coinsurance for the upper endoscopy and other 
medical services provided on May 5, 2022. 
 
You have been asked to pay 15% coinsurance for the upper endoscopy and other medical services. These 
items/services fall within outpatient surgery, including services provided at hospital outpatient facilities benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for the upper endoscopy and other medical 
services provided on May 5, 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.