Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre reader kit. 
 
You asked the Plan to pre-approve the FreeStyle Libre reader kit. You say that the Freestyle is a great choice of 
glucose monitor due to the enrollee is legally blind. You also say that the monitor will be able to help her track 
her records for her glucose levels on her phone.  The Plan denied your request. The Plan says the enrollee is not 
on insulin and is on oral agents for diabetes only. No hypoglycemia is reported. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Libre reader kit. Our 
reviewer says that the requested item is not medically necessary. Our physician reviewer found coverage 
criteria for CGM require insulin use or low blood glucose sugar. The enrollee is not on medications that would 
cause low blood glucose sugar. Although the enrollee is legally blind and would have difficulty using and 
seeing a handheld meter/fingerstick meter, it is unclear what the checking of blood glucose sugar would add to 
their care. The enrollee is at a A1C goal and on medications that do not cause low blood glucose sugar. As the 
enrollee does not meet criteria for the CGM coverage and there is no strong reason given why there is a need to 
be monitoring blood glucose sugar, the CGM would not meet provided medical necessity criteria. 
 
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 FreeStyle Libre reader kit have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a FreeStyle Libre reader kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 29, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service May 22, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service May 23, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service May 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service May 10, 
2023.  
 You asked the Plan to pay for procedure code 76641. You say that 2 units of 76641 should be paid as billed 
because they are supported in the record and were billed with different modifiers. The Plan denied your 
request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the units of service 
exceed the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service May 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute 
care and is currently unstable for 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 the enrollee appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex/Superion Interspinal Spacer system. 
 
You asked the Plan to pre-approve the Vertiflex/Superion Interspinal Spacer system. You say that the 
Vertiflex/Superion Interspinal Spacer system is medically necessary. The Plan denied your request. The Plan 
says the Vertiflex/Superion Interspinal Spacer system is not medically necessary for the treatment of spinal 
stenosis. 
 
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 Vertiflex/Superion Interspinal 
Spacer system. Our reviewer says that the requested Vertiflex/Superion Interspinal Spacer system is not 
considered medically reasonable and necessary. Our physician reviewer found that the enrollee was being 
treated for spinal stenosis of the lumbar region with neurogenic claudication. The enrollee presented with low back pain. However, current evidence based medical guideline and peer reviewed literature do not fully support 
the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
medical condition as discussed above. The Food and Drug Administration (FDA) indications include 
implantation of the Vertiflex/Superion Interspinal Spacer device at one or two adjacent lumbar levels in 
patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, 
from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of 
moderate spinal stenosis (including the planned level of implantation at L4-5.) FDA contraindications 
include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the 
medical records. There is no discussion of spinal instability on flexion/extension films. There is no discussion 
of scoliosis of the lumbar spine with no documentation of the Cobb angle. There is no discussion indicating 
that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception.  
 
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 Vertiflex/Superion Interspinal Spacer system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Vertiflex/Superion Interspinal Spacer system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27350 rendered on June 1, 2023. 
 
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 code 27350 is "Patellectomy or hemipatellectomy." 
 
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 procedure details cite an 
excisional debridement of the quadriceps tendon and patella fragments was performed. This does not 
corroborate that this was a separate procedure; however, supports the patellar fragments were removed to allow for reattachment of the quadriceps tendon. Therefore, the documentation does not support CPT 27350: 
patellectomy or hemipatellectomy as a separate and distinct procedure from CPT 27385: suture of quadriceps 
or hamstring muscle rupture, primary. 
 
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 code 27350 rendered on June 1, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor-controlled ankle foot system (L5973). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 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 item. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that one of the criteria that is sufficient for replacement of a prosthesis/component per Policy Article 
A52496 is change in the physiological condition of the beneficiary.  Meanwhile the medical record provided 
establishes that his functional potential has improved since his existing prostheses were designed, and this 
certainly is accepted as a sufficient physiological change to approve coverage of replacement componentry. 
 
And, though, as a bilateral amputee, he is not strictly bound by Medicares functional level criteria, the medical 
record also establishes his K3-activity level, and specific reasonableness and necessity of the requested 
microprocessor foot. LCD L33787 explicitly establishes that L5973 is covered for K3-level ambulators, 
without further specific documentary requirements, since this foot is part of the mainstream standard of care for 
an ambulator like this enrollee. 
 
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 item have been met. Therefore, we decided that the Plan has to pre-approve 
a microprocessor-controlled ankle foot system (L5973).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code Q9967 billed for date of service April 11, 2023. 
 You asked the Plan to pay for code Q9967. You say that the patient was seen for a scan of the abdomen, and 
you have provided the results to support payment of this code. The Plan denied your request. The Plan says the 
diagnosis code at issue is not appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code I25.84. This code 
is not an appropriate primary diagnosis as the code has a code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for code Q9967 billed for date of service 
April 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99306 rendered on November 25, 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 code 99306 is "Initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient's facility floor 
or unit."  
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 medical decision making is 
not of high complexity. As such, the billing of CPT 99306 is not supported. 
 
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 code 99306 rendered on November 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient therapies-hydration infusion 
therapy provided from January 20, 2023, to February 28, 2023.  
 
You asked the Plan to waive the copayment for outpatient therapies- hydration infusion therapy. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
 You have been asked to pay a $50 copayment for outpatient therapies- hydration infusion therapy. This service 
falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers 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 copayment for outpatient 
therapies-hydration infusion therapy provided from January 20, 2023, to February 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray and the screening mammogram provided on 
April 13, 2023. 
 
You asked the Plan to pay for the chest x-ray and the screening mammogram. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the chest x-ray and the 
screening mammogram provided on April 13, 2023.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99223, 99233, 99233, 
99233, 99233, and 99238. We decided that the Plan does not have to pay for the services described by 
procedure code(s) 99497.  
 
You asked the Plan to pay for the evaluation and management services described by codes 99497, 99223, 
99233, 99233, 99233, 99233, and 99238 billed on March 19, 2023, through March 24, 2023. You say that the 
evaluation and management services should be covered as billed because they are supported in the medical 
record. The Plan says that payment for code 99497 is bundled into payment for code 99223 billed on the same 
date of service. Codes 99223, 99233, 99233, 99233, 99233, and 99238 were handled as an original decision 
reopen for New and Material Evidence, therefore no appeal decision was made. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99223, 99233, 99233, 
99233, 99233, and 99238.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 99223, 99233, 99233, 99233, 
99233, and 99238.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99497.   
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, we have confirmed that code 99497 is a column II code 
to column I code 99223. This claim has not been billed with an appropriate modifier to bypass the edit. Based 
on this information, we decided that Medicare rules for coverage of the services described by procedure code(s) 
99497 have not been met. Therefore, we decided that the Plan does not have to pay for the services described 
by procedure code(s) 99497. 
 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.