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

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not show that the enrollee meets criteria for medical 
necessity. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
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 you are requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
guidelines for services in 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary because based on the medical literature this 
procedure is considered experimental or investigational and has not been proven to be beneficial for the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental/investigational therapy at this time. It is the subject of 
ongoing clinical trials.  
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 24, 2023, to 
April 22, 2023. 
 
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 March 24, 2023, to April 
22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87798, 87641, 87653, 87500, 87640 and 
87481) provided on March 28, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R39.15 has an Excludes1 note in relation to N39.41. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for laboratory services (87798, 87641, 87653, 87500, 87640 and 87481) provided on March 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for coronary 
angiography (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that you want to appeal this denial. The 
Plan denied your request. The Plan says this 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 cardiac catheterization. Our reviewer 
says that the requested cardiac catheterization not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not indicate that the enrollee has chest pain. 
The enrollee has had no non-invasive evaluation, such as a stress test. The medical records provided do not 
support the rationale for this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this setting. Therefore, the requested cardiac catheterization is not medically appropriate 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve catheter placement in coronary artery(s) for coronary angiography (93458).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy provided on May 08, 2023. 
 
You asked the Plan to pay for the chemotherapy. You say that you are requesting reconsideration of the denied 
claim. 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 chemotherapy 
provided on May 08, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a psychiatric evaluation provided on April 
26, 2023. 
 
You asked the Plan to waive the copayment for a psychiatric evaluation. You say that you disagree with the 
copayment. 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 $30 
copayment for in-network outpatient mental health care. 
 
You have been asked to pay a $30 copayment for a psychiatric evaluation. This item/service falls within the in-
network outpatient mental health care 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 a 
psychiatric evaluation provided on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64493, 64494, and S0020 billed for date of 
service February 21, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed 
services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid 
when the MAI value is 2. In this case, the MUE for CPT code 64493 is 1. The MAI value for this code is 2. 
You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules 
for coverage have not been met. 
 
In this case, we have confirmed that code 64494 is an add-on code. Because the primary procedure code, 
64493, is not payable in this case, this add-on code is also not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. 
 
We find that procedure code S0020 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0020 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 64493, 64494, and S0020 billed for date of service February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 4, 2023, billed with 
procedure code 99152-59-GA. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99152-59-GA is moderate sedation services provided by 
the same physician or other qualified health care professional performing the diagnostic or therapeutic service 
that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring 
of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient 
age 5 years or older.  
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the records in this case do not 
document the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status as is required for code 99152.  
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 4, 2023, billed with procedure code 
99152-59-GA.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 80048, 36415 and P9604 billed for date of 
service July 11, 2022. 
 
You asked the Plan to pay for procedure code(s) 80048, 36415 and P9604. You say that please find the 
attached documentation and reconsider the claim towards payment. The Plan denied your request. The Plan 
says this code is included in the skilled nursing facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 80048, 36415 and P9604 has a Professional/Technical indicator of 1. This means that CPT 
code 80048, 36415 and P9604 has both a professional and technical component. In this case, CPT code 80048, 
36415 and P9604 has not been billed with an appropriate modifier to indicate the professional component. 
Based on this information, we decided that Medicare rules for coverage of procedure code 80048, 36415 and 
P9604 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
80048, 36415 and P9604 billed for date of service July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS system. 
 
You asked the Plan to pre-approve the CardioMEMS system. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMS system. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental. 
 
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 CardioMEMS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 for date of service May 
31, 2023. 
 
You asked the Plan to pay for procedure codes 96365 and 96366. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the evidence is adequate to conclude that 
outpatient intravenous (IV) insulin therapy (OIVIT) does not improve health outcomes in Medicare 
beneficiaries. 
 
 We looked at the file and Medicare rules. Review of the file shows that the services at issue are OIVIT. These 
services are not covered. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 96365 and 96366 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 96365 and 96366 for date of service May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that the coding and diagnosis are approved by 
Medicare. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. We find that the urinary tract infection panel test was not billed with 
a single code as required. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on April 27, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 
87500.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on November 12, 2022, billed 
with evaluation and management code 99222-AI. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99222-AI is Initial hospital 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 moderate 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 moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the provided records in this case do 
not document a general multisystem examination or a complete examination of a single organ system. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on November 12, 2022, billed with evaluation 
and management code 99222-AI.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee needs 
transportation for medical appointments. The Plan denied your request. The Plan says the enrollee has utilized 
the maximum number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes G0453 and 95861 for date of service May 1, 2023. 
 
You asked the Plan to pay for codes G0453 and 95861. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes G0453 and 95861 are not payable as billed. Specifically, the submitted medical 
records do not include the duration of monitoring. This means the number of units billed for code G0453 
cannot be verified. The submitted medical records do not indicate that needle electromyography; 2 extremities 
with or without related paraspinal areas was performed; therefore, code 95861 cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of codes G0453 and 95861 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes G0453 and 95861 for date of service May 1, 
2023.