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

 
We decided that the Plan does not have to pay for selective catheter placement (36253) provided on April 5, 
2023. 
 You asked the Plan to pay for catheter placement. You say that the medical records submitted supports code 
36253 and should be paid. The Plan denied your request. The Plan says CPT code 36253 is included in code 
37244; therefore, it cannot be separately reimbursed. The documents received do not support that the procedure 
or service was distinct or independent from other services performed; therefore, the use of the 59 modifier is 
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. 
 
In this case, we have confirmed that code 36253 is a column II code to column I code 37244; however, 36253 
was billed with a modifier.  
 
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 catheter placement. Our reviewer found CPT code 36253 is 
bundled with code 37244. The medical records provided do not include sufficient documentation to validate 
that 36253 was a distinct procedure, performed independent from other services performed on April 5, 2023, 
therefore it is not appropriate to use modifier 59 to unbundle these codes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of catheter placement have not been met. Therefore, we decided that the Plan does 
not have to pay for selective catheter placement (36253) provided on April 5, 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 you are requesting reconsideration for the denial of 
an IRF admission based on medical necessity. The Plan denied your request. The Plan says admission to an 
IRF is not reasonable and necessary.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6751) for tooth #18, #20, #21, and 
#31, and pontic (D6245) for tooth #19 and #30. 
 
You asked the Plan to pre-approve D6751 and D6245. You say that the cavities are painful, and the dentist says 
it is time to extract the teeth. The Plan denied your request. The Plan says the medical criteria for D6751 and 
D6245 have not been met. 
 
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 Plan covers D6751 and 
D6245 when the services are medically necessary and reasonable.  
 
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 D6751 and D6245. Our reviewer says 
that this dental work is not medically necessary. Our physician reviewer found according to the plan, fixed bridges may be covered to replace a single maxillary anterior tooth or two adjacent mandibular anterior teeth if 
there are no posterior teeth missing. In this case, two mandibular posterior teeth are being replaced. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D6751 and D6245 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a retainer crown (D6751) for tooth #18, #20, #21, and #31, and pontic (D6245) for 
tooth #19 and #30.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on April 27, 2023, and billed with codes 87511, 87529, 87591, 87661, 87641, 87500, 87532, G0452, 
87653, 87798, 87563, 87496, 87481, 87651, and 87491. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel testing provided on April 27, 2023, and billed with codes 87511, 87529, 87591, 87661, 87641, 87500, 
87532, G0452, 87653, 87798, 87563, 87496, 87481, 87651, and 87491.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan (93930) provided on April 3, 2023. 
 
You asked the Plan to pay for the duplex scan. You say that this procedure was performed at the request of the 
referring doctor, as the patients medical condition proved the medical necessity for the service. The Plan 
denied your request. The Plan says the billed number of units are not supported by the records as both provided 
and medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 93930 is 1 per day. The MAI value for this code is 3. You billed 2 units of 
this code, exceeding the MUE.  
 
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 93930. Our reviewer found the provider did 
not document any reason for performing extra units in excess of the 1 allowed. The records did not support that 
the additional services were reasonable or necessary in this case. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 93930 have not been met. Therefore, we decided that the Plan does not have to 
pay for the duplex scan (93930) provided on April 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on March 21, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483) provided on March 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nasal airway remodeling using the Vivaer ARC Stylus. 
 
You asked the Plan to pre-approve nasal airway remodeling. You say that Original Medicare covers nasal 
airway remodeling. You also say that this should be covered. 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 nasal airway remodeling. Our reviewer 
says that the requested nasal airway remodeling using the Vivaer ARC Stylus is not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the provided medical records and 
review of the current peer-reviewed medical literature do not document that nasal airway remodeling using the 
Vivaer ARC Stylus has been shown in controlled studies in a CMS-approved journal to result in long term health benefits in patients with nasal congestion. Therefore, the reviewer found that the requested nasal airway 
remodeling with the Vivaer ARC Stylus is 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 nasal airway remodeling have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nasal airway remodeling using the Vivaer ARC Stylus.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87637) provided on March 8, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87637) provided on March 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure address vertebrogenic 
pain by addressing a gap in the treatment algorithm for those suffering from chronic low back pain. 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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not show a clear cause for the enrollee's pain. 
Therefore, the reviewer found that the requested Intracept procedure is 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (00840) provided on February 23, 
2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says only one anesthesia 
code is payable. 
 
The Plan must follow Medicare rules. Medicare rules say that anesthesia codes describe a general anatomic 
area or service which usually relates to a number of surgical procedures, often from multiple sections of the 
CPT Manual. For Medicare purposes, only one anesthesia code is reported unless the anesthesia code is an 
Add-on Code (AOC). 
 
We looked at the file and Medicare rules. The records show that anesthesia code 00811 was billed and paid for 
the same date of service and same provider. As only one anesthesia code should be reported for each anatomic 
region, code 00840 is not payable in this case. 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 the 
anesthesia services (00840) provided on February 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 screening (0202U) provided October 23, 
2022, through October 26, 2022. 
 
You asked the Plan to pay for the COVID-19 screening (0202U). You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this code is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0202U is non-covered.  
 
We looked at the file and Medicare rules. The code at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the COVID-19 screening (0202U) have not been met. Therefore, 
we decided that the Plan does not have to pay for the COVID-19 screening (0202U) provided October 23, 
2022, through October 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 24, 2023, billed with 
codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240-59, 81241-59, 81291-59, 81306-59, 81328-59, 
81335-59, 81479-GY-59, 81238-59. 
 
You asked the Plan to pay for the genetic testing billed. You say that please review medical records and 
process claim for payment. 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. This was an NGS panel that was not billed with a single panel 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 24, 2023, billed with codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240-59, 81241-59, 81291-
59, 81306-59, 81328-59, 81335-59, 81479-GY-59, 81238-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care (99225) provided from November 19, 
2022, to November 26, 2022. 
 
You asked the Plan to pay for the 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. 
 
In this case, the CPT Code Manual definition of code 99225 is "Subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; 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 patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit". 
 
We find that CPT code 99225 is not supported in the medical record. Specifically, the records do not show that 
the enrollee was under observation care when the services were provided. 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 the observation care (99225) provided from November 19, 2022, to November 26, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a transcutaneous electrical nerve stimulation (TENS) device (A4595) 
provided December 22, 2022. 
 
You asked the Plan to pay for a TENS device. You say that please reprocess these tens supplies A4595 as per 
the clinical policy bulletin for electric stimulation for pain, medical necessity has been met. The Plan denied 
your request. The Plan says that the supplies are considered experimental and investigational by the Plan and is 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for a TENS device. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this is for electrical stimulation of the enrollee's muscles that have atrophied even though the 
enrollee's innervation is intact. Electrical stimulation is medically reasonable and necessary and so are the 
supplies. 
 
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 TENS device have been met. Therefore, we decided that the Plan has to pay 
for a transcutaneous electrical nerve stimulation (TENS) device (A4595) provided December 22, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent and active before coming to 
the hospital and wish to return to being independent as quickly as possible. The Plan denied your request. The 
Plan says the IRF services requested do not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the medical record overall significantly complies with the various documentation requirements for 
IRF admission. Your condition is in fact complex and fragile, and there is every reason to expect that you will 
participate in and benefit from services to include at minimum physical therapy, occupational therapy, 
physician oversight of post-op course, polypharmacy and cardio/renal comorbidities, case manager 
coordination of any additional services that might be needed to make a sustainable return home, as well as 
avoid preventable readmissions to the acute hospital. Therefore, the requested IRF admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Spinal Simplicity interspinous-interlaminar fusion 
device (Minuteman device).  
 
You asked the Plan to pre-approve the Minuteman device. You say that this procedure is necessary to alleviate 
the enrollee's pain. The Plan denied your request. The Plan says the use of this device as a stand-alone 
procedure has not been shown to be safe and effective in long term studies. 
 
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 Minuteman device. Our reviewer 
says that the requested Minuteman device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found information from the Food and Drug Administration (FDA) and manufacturer 
state that this device is intended for use with bone graft material and is not intended for stand-alone use. There is no indication that this physician plans to use this Minuteman device in conjunction with an open back 
surgery or in conjunction with a spine surgeon. Therefore, the requested Minuteman device is deemed not 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Spinal Simplicity interspinous-interlaminar fusion device (Minuteman 
device).