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

 
We decided that the Plan does not have to pay for procedure codes 93923 and 93922 provided July 28, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 93923 is 9omplete bilateral noninvasive physiologic 
studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at 
distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements 
with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at 
distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or 
more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus 
segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with 
reactive hyperemia). The definition of code 93922 is limited bilateral noninvasive physiologic studies of upper 
or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior 
tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or 
ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume 
plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis 
pedis arteries with, transcutaneous oxygen tension measurement at 1-2 levels). 
 
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 found the medical records do not 
support the use of procedures 93923 and 93922, the provider ordered such procedures to be done in the future; 
however, in the visit with the provider on July 28th there were no procedures performed, only review of tests 
and additional tests ordered. These procedures are not able to be verified. 
 
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 93923 and 93922 provided July 28, 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 the enrollee needs this care to restore 
prior level of functioning. The Plan denied your request. The Plan says medical records do not support the need 
for an LTACH admission and, the enrollee needs can be provided at another setting.  
 
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 is receiving appropriate care in their current acute care setting. The 
documentation does not support that LTACH services are medically appropriate at this time. 
 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: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing (81404). 
 
You asked the Plan to pre-approve genetic testing. The Plan denied your request. The Plan says that the records 
we received did not contain certain details that are needed to process this request. 
 
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 records received did not contain certain details that are 
needed to process this request. We find that the Plan did not attempt to obtain the necessary documentation 
from the requested provider, who is contracted with the Plan. As such, the Plan has not provided 
documentation supporting its denial, and therefore the Plan's denial cannot be substantiated. Therefore, we 
decided that the Plan has to pre-approve genetic testing (81404).  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for dermatology services provided on July 12, 2023. 
 
You asked the Plan to pay for the dermatology services. You say that you had a referral for these services. The 
Plan denied your request. The Plan says that unauthorized, non-plan care is not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the dermatology services by a contract provider. You have provided a copy of the 
referral provided to you by the enrollee's Primary Care Physician. The file does not show that the plan provided 
notice that the dermatology services would not be covered. Under Medicare rules, this means the dermatology 
services is considered approved by the plan. Therefore, we decided that the Plan has to pay for dermatology 
services provided on July 12, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre Kit 2 CGM sensor. You say that you disagree with the 
denial and have submitted medical records including complete diagnosis and medication history.  The Plan 
denied your request. The Plan says the enrollee is not on insulin or does not have documentation of recurrent 
problematic hypoglycemia. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre Kit 2 CGM sensor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre Kit 2 continuous glucose monitor (CGM) sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous kyphoplasty (22513). 
 
You asked the Plan to pre-approve the percutaneous kyphoplasty is not medically necessary. You say that the 
enrollee has tried and failed multiple modalities of conservative care including greater than 8 weeks of 
physical-guided home exercise including stretching and strengthening as well as medication therapy consisting 
of narcotic, non-steroidal anti-inflammatory drugs, and anticoagulants. The Plan denied your request. The Plan 
says the percutaneous kyphoplasty is not medically necessary.  
 
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 percutaneous kyphoplasty is not 
medically necessary. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that more conservative management such 
as pain medication and bracing must be tried and failed. 
 
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 percutaneous kyphoplasty is not medically necessary.  have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the percutaneous kyphoplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), an extraction 
(D7140) for tooth #3, #4, #5, #12, #13, and #14, and analgesia (D9239 and D9243) and to pay for the surgical 
placement of implant body (D6010) for tooth #4, #7, #10, and #13, a prefabricated abutment (D6056) for tooth 
#4, #7, #10, and #13, an implant fixed to denture (D9119), a surgical implant (D6190), and an occlusal guard 
(D9940) provided by an out-of-network provider on February 16, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are trying to recover your money that 
you spend on the dental services. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Also, charges for any type of implant and all related services and an occlusal guard are not covered 
by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The total amount billed for the comprehensive oral evaluation (D0150) was $1,000 and the total allowed 
amount was $37 leaving a difference of $963 ($1,000 billed - $37 allowed). The total amount billed for a single 
extraction (D7140) was $112.50 and the total allowed amount was $71 leaving a difference of $41.50 ($112.50 
billed - $71 allowed). There was a total of 6 extractions (D7140) having a total difference amount for all 6 of 
$249 ($41.50 difference x 6 extractions). The total amount billed for the analgesia (D9239) was $1,000 and the 
total allowed amount was $253 leaving a difference of $747 ($1,000 billed - $253 allowed). The total amount 
billed for the analgesia (D9243) was $1,000 and the total allowed amount was $253 leaving a difference of 
$747 ($1,000 billed - $253 allowed). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
implant and related services and the occlusal guard are not covered under the Plans dental benefit. Therefore, 
we decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), an extraction 
(D7140) for tooth #3, #4, #5, #12, #13, and #14, and analgesia (D9239 and D9243) and to pay for the surgical 
placement of implant body (D6010) for tooth #4, #7, #10, and #13, a prefabricated abutment (D6056) for tooth 
#4, #7, #10, and #13, an implant fixed to denture (D9119), a surgical implant (D6190), and an occlusal guard 
(D9940) provided by an out-of-network provider on February 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the 
enrollee's complex care needs. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for admission to an IRF.  
 
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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation provided on February 17, 
2023. 
 
You asked the Plan to pay for the interrogation device evaluation. You say that you are requesting 
reconsideration for the denied authorization stating the member has a PPO plan and not require a prior 
authorization. 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 interrogation device 
evaluation provided on February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95700, 95705, and 95708 rendered on May 
5, 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 the denied codes is: 
 
CPT 95700: 
 
Electroencephalogram (EEG) continuous recording, with video when performed, setup, patient education, and takedown when performed, administered in person by EEG technologist, minimum of 8 channels 
 
CPT 95705: 
 
Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, 2-12 
hours; unmonitored 
 
CPT 95708: 
 
Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, each 
increment of 12-26 hours; unmonitored 
 
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 in this case, the clinical 
information provided for review is limited to an electroencephalogram (EEG) interpretation report. No formal 
documentation was provided demonstrating that "Electroencephalogram (EEG) continuous recording, with 
video when performed, setup, patient education, and takedown when performed, administered in person by 
EEG technologist, minimum of 8 channels" (records of this having been done were not provide - and in the 
absence of records it is not appropriate to "assume" said service was rendered). 
 
For the remainder of the EEG study there was no indication that the following required component had been 
performed: "technical description by EEG technologist".  Rather there was only the interpreting physician's 
review of push button events noted.  Ultimately, given the paucity of documentation provided, the CPT codes 
under review cannot be said to be supported at this time.  
 
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 95700, 95705, and 95708 rendered on May 5, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323). 
 You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says step-therapy rules for coverage of Euflexxa have not been 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 Euflexxa. Our reviewer says that 
treatment with Euflexxa is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of drug Orthovisc or Supartz FX before they will approve the requested drug. In 
this case, the enrollee has not tried and failed the required drugs. There is no documentation provided 
indicating that the Plans required drugs would likely be less effective and/or likely have adverse effects for the 
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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks (64494 and 64493). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 services. Our physician reviewer 
found the enrollee has had a previous lumbar radiofrequency ablation and there is no documentation indicating 
that the previous therapeutic facet joint procedures at the same anatomic site resulted in at least consistent 50 
percent relief of pain for at least three (3) months from the prior therapeutic procedure or at least 50 percent 
consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale. The review has determined that the records do not support that the 
criteria for coverage in LCD L38801 are met. The services are 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve medial branch blocks (64494 and 64493).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 14, 2023, to 
May 18, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says the medical 
records did not have sufficient documentation to clinically validate the diagnosis of G93.6 (Cerebral edema) 
and I21.A1 (Myocardial infarction type 2). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis codes G93.6 (Cerebral edema) and 
I21.A1 (Myocardial infarction type 2). We asked our physician reviewer to carefully review the case file and 
apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
inpatient hospital services at the DRG originally billed. Our physician reviewer found that the records did not 
show evidence of cerebral edema and the symptoms didn't include vision changes or other signs of cerebral 
edema, or treatment. Also, the patient did not report any chest pain or shortness of breath to support the 
diagnosis of myocardial infarction. Therefore, diagnosis codes G93.6 (Cerebral edema) and I21.A1 
(Myocardial infarction type 2) are not supported in the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 14, 2023, to May 18, 2023, at the Diagnosis Related Group 
(DRG) originally billed.