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

 
We decided that the Plan does not have to pay for the eye prostheses billed with codes V2628 and V2624. 
 
You asked the Plan to pay for the eye prostheses. You say that these items were authorized, and the Plan 
shouldn't have authorized them if they weren't going to get paid. The Plan denied your request. The Plan says 
you did not bill these items with the required modifier, 
 
The Plan must follow Medicare rules. Medicare rules say that the right (RT) and/or left (LT) modifiers must be 
used with all eye prosthesis codes.  You did not bill the eye prosthesis codes in dispute with a RT or LT 
modifier as is required. Therefore, we decided that the Plan does not have to pay for the eye prostheses billed 
with codes V2628 and V2624.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services (90935) provided on September 3, 2022. 
 
You asked the Plan to pay for dialysis services. You say that this is supported in the records. The Plan denied 
your request. The Plan says this is not covered as a telehealth service. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face to-face service. However, there are two 
exceptions to this general rule  these are for a service rendered to a patient who is a registered inpatient or an 
outpatient of a hospital.  
 
We looked at the file and Medicare rules. The submitted records indicate that the services at issue took place in a hospital, but the services were not billed with a hospital POS. Based on this information, we decided that 
Medicare rules for coverage of dialysis services have not been met. Therefore, we decided that the Plan does 
not have to pay for dialysis services (90935) provided on September 3, 2022.
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 in danger of being currently discharged and 
if you go home from the hospital without rehab, you are at risk of falling again and may end up readmitted to 
the hospital and possibly die due to the fall. You need assistance walking and getting in and out of bed. You are 
able to use a walker, but you still need assistance with using the walker currently. The Plan denied your 
request. The Plan says the requested admission to an IRF does not meet criteria. 
 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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days 
a week, or 15 hours over seven consecutive days. As of May 22, 2023, you required moderate assistance with 
bed mobility and maximum assistance for transfers. You required set up assistance for grooming. You have had 
a decline from your baseline level of function and would likely benefit from occupational and physical 
therapies and assistance, but you do not require the intensity of therapies provided on acute inpatient 
rehabilitation. Therefore, the acute inpatient rehabilitation admission is not medically 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 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 procedure code 99100 billed for date of service January 8, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 8, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a psychiatric diagnostic evaluation provided on August 22, 2022. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. The Plan denied your request. The Plan 
says that this provider type is not eligible in the Medicare program. 
 
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 has not provided a Medicare rule to substantiate their 
denial. Therefore, we decided that the Plan has to pay for a psychiatric diagnostic evaluation provided on 
August 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: 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's needs are complex and are 
unable to be met in a lower level of care.  The Plan denied your request. The Plan says the enrollee's medical 
needs are being met in the current facility.  
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy administration (96402), Leuprolide acetate 
suspension (J9217), collection of venous blood by venipuncture (36415), and complete blood count (85025) 
provided on July 20, 2022, by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the chemotherapy administration, Leuprolide acetate suspension, collection of 
venous blood by venipuncture, and complete blood count. You say that you have authorization for Leuprolide 
acetate suspension (J9217), and you would like this claim to be reprocessed. The Plan denied your request. The 
Plan says services from a non-participating provider are not covered unless preauthorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The authorization provided 
specifically states that services may be limited if the treating provider is OON. We found no exception that 
would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay 
for the chemotherapy administration (96402), Leuprolide acetate suspension (J9217), collection of venous 
blood by venipuncture (36415), and complete blood count (85025) provided on July 20, 2022, by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 28, 
2022, through December 29, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.   
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) with a sore throat, and was later 
diagnosed with pharyngitis, probably an early peritonsillar abscess. The computed tomography (CT) scan 
showed enlargement of a right palatine tonsil with a right supraglottic mass. She was treated with antibiotics, 
pain medication, steroids, viscous lidocaine, and Motrin. She was non-toxic appearing with stable vitals and no 
swallowing or breathing difficulty. While awaiting an ears, nose, and throat (ENT) consultation, the enrollee 
left against medical advice. Based on the documentation provided, without the ENT consultation, plans for an 
invasive procedure or treatment, without instability or complexity of the case, and the fact that the enrollee left 
against medical advice, it was not expected that the enrollee would require hospital care that would likely cross 
two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from December 28, 2022, through December 29, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
(IONM) (G0453) provided on August 31, 2021.  
 
You asked the Plan to pay for the continuous IONM. You say that these services are medically necessary 
services requested by an in-network surgeon. You also say that you would like payment to be remitted 
accordingly. The Plan denied your request. The Plan says the time frame for the Plan to make a determination 
on this request has expired. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the continuous IONM. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found given the conflicting evidence to date and the overarching consensus that further 
study is necessary to evaluate the use of IONM in lumbar spine surgery, the requested service is not supported 
as medically 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 continuous IONM have not been met. Therefore, we decided that the Plan 
does not have to pay for the continuous intraoperative neurophysiology monitoring (IONM) (G0453) provided 
on August 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36478 billed for date of service November 9, 
2021.  
 
You asked the Plan to pay for procedure code 36478. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 36478 is bundled into payment for code 36475. 
 
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 36478 is a column II code to column I code 36475 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met.  Therefore, we decided that 
the Plan does not have to pay for procedure code 36478 billed for date of service November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the HA Minuteman G3-R MIS Fusion Plate is intended for use with bone 
graft material and is not intended for stand-alone use. This request is being made as a stand-alone use. In 
addition, fusion indications within guidelines/literature for (existing or potential intraoperative) instability have not been documented and/or met in this case. There are multiple alternate pain generators plausibly 
significantly contributing to the clinical condition that have not been fully documented as having been excluded 
and/or ruled out. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Minuteman procedure, in this case, 
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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
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 the genicular nerve block. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says this procedure is not proven for the enrollee's condition 
and is non-covered. 
 
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 genicular nerve block. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found this procedure is the subject of ongoing clinical trials. More research is needed to 
show safety and efficacy. 
 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 4, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuroplasty and/or transposition; median nerve at carpal 
tunnel rendered on November 1, 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 CPT 64721 is considered inclusive to CPT 25024. 
 
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 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 records do not support CPT 
64721: neuroplasty and/or transposition; median nerve at the carpal tunnel was a separate and distinct 
procedure from CPT 25024: decompression fasciotomy, forearm, and/or wrist, flexor, and extensor compartment. The procedure details cite the incision was continued into the thenar, hypothenar eminence 
carried through skin, subcutaneous tissue, and then through palmer aponeurosis. The median nerve was located 
just proximal to the wrist crease. The flexor retinaculum was released across the wrist from proximal to distal 
all the way to the palmar arch, completely decompressing the carpal tunnel. There was noted to be pressure on 
the nerve in the carpal tunnel. On completion, the nerve was completely decompressed. After this was 
completed, attention was then turned to the extensor compartments. However, the procedure details describe a 
carpal tunnel release having been performed. There is no indication of a neuroplasty and/or transposition 
having been performed on this operative date. A more appropriate code for this carpal tunnel release could be 
29848. 
 
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 neuroplasty and/or transposition; median nerve at carpal tunnel rendered on November 1, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for physician's services for an emergency department visit provided on 
May 31, 2022. 
 
You asked the Plan to pay for physician's services for an emergency department visit. You say that you have 
provided proof of enrollment from CMS for this provider. The Plan denied your request. The Plan says that this 
provider has been precluded from participation in Medicare at the time services were rendered. The Plan is not 
permitted to issue payment to providers on the Preclusion List. 
 
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 has not provided documentation showing that this 
physician (NPI 1285083519) and/or the billing group (NPI 1861430555) have been precluded from 
participation in Medicare at the time services were rendered. Therefore, we decided that the Plan has to pay for 
physician's services for an emergency department visit provided on May 31, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) rendered on 
January 3, 2023. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in 
clinical management exceeds the needs of the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the medical record sent by the provider shows a definitive UDT panel for multiple drug classes was 
performed, but does not show screening test results which are positive or inconsistent with prescription 
medications, dosing schedules, or history and expected results. The review has determined that the enrollee did 
not need 22+ drug classes tested. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for drug testing services (procedure code G0483) rendered on January 3, 2023.