Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 36 additional occupational therapy (OT) visits.  
 
You asked the Plan to pre-approve the therapy services. You say that the additional OT visits are necessary. 
The Plan denied your request. The Plan says the remaining 24 additional requested OT visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has responded to therapy and has a home exercise 
program. The enrollee will need to continue with a home exercise program regardless of the number of therapy 
visits approved. Based on the documentation provided, continued input from a skilled therapist is not necessary 
for the additional 24 OT visits. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 36 additional occupational therapy (OT) visits.
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 addresses vertebrogenic 
pain by addressing a gap in treatment for those suffering from chronic low back pain. You also say that the 
enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says 
this is considered experimental and therefore is not 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87481, 87653, 87798, and 87801 for date of service 
May 17, 2023. 
 
You asked the Plan to pay for codes 87481, 87653, 87798, and 87801. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Review of the file shows that the services at issue are billed as 
individual codes rather than one code for the entire panel. Based on this information, we decided that Medicare 
rules for coverage of codes 87481, 87653, 87798, and 87801 have not been met. Therefore, we decided that the 
Plan does not have to pay for codes 87481, 87653, 87798, and 87801 for date of service May 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure. 
 
You asked the Plan to pre-approve the VivAer procedure. You say that Medicare Advantage Plans are required 
to cover anything that Original Medicare covers. You says that Original Medicare covers nasal airway 
remodeling using the codes requested. The Plan denied your request. The Plan says the requested VivAer 
procedure (intranasal radiofrequency ablation) is not medically necessary. Medical studies have not proven this 
service is helpful for the treatment of this health problem. 
 
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 VivAer procedure. Our reviewer 
says that the requested VivAer procedure is not considered medically reasonable and necessary. Our physician 
reviewer found that the record indicates that the enrollee has nasal obstruction and congestion with valvular collapse. There is insufficient literature to support the safety and efficacy of the requested service for the 
enrollee's specific clinical scenario. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service.  
 
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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93620 and 93621 billed for date of service 
June 1, 2023.  
 
You asked the Plan to pay for procedure codes 93620 and 93621. You say that you have provided the operative 
note and consult note to support payment. The Plan denied your request. The Plan says payment for codes 
93620 and 93621 is bundled into payment for code 93653. 
 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 codes 
93620 and 93621 are column two codes to column one code 93653 with a modifier indicator of 0. The column 
two codes are 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 codes 93620 and 93621 billed for date 
of service June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 95861 rendered on August 12, 
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 there was no medically necessary reason for performing the extra units.  
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 95861 is "Needle electromyography; 2 extremities with 
or without related paraspinal areas." 
 
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 provided records in this case 
document a bilateral lower extremity electromyography was monitored throughout the surgical procedure; the 
records do not clarify that a second unit of CPT 95861 was rendered. Additionally, the records do not support 
that it was medically reasonable and necessary to render these extra services. 
 
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 two units of procedure code 95861 rendered on August 12, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 36556 rendered on May 27, 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 that procedure code 36556 rendered on May 27, 2023. 
 
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 36556 is "Insertion of non-tunneled centrally inserted central venous catheter; 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the documentation supports that the 
services in question were rendered and appropriately coded. There is satisfactory documentation that a central 
line was placed via the internal jugular vein. There is satisfactory documentation that the line was placed 
centrally. As most central lines placed perioperatively are not placed under fluoroscopic guidance, the exact 
location of the tip cannot be documented, and it is not reasonable to require this information to justify billing.  
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 36556 rendered on May 27, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150 and 87500 (x2) provided on 
December 13, 2022. 
 
You asked the Plan to pay for procedure codes 87150 and 87500 (x2). You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these codes are 
not supported in the medical record. 
 
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 procedure codes 87150 and 87500 (x2). Our reviewer says 
that these codes are not supported. Our reviewer found the laboratory report does not support code 87150 and 
two units of 87500. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150 and 87500 (x2) have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87150 and 87500 (x2) provided on December 
13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 23, 2023, billed with 
codes 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87641, 87651, 87798, and U0005. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 
January 23, 2023, billed with codes 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87641, 87651, 
87798, and U0005.
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 record documents the presence of non-vertebrogenic pathology per 
clinical assessment and radiology studies that could explain the source of pain, including findings of moderate 
degenerative changes and posterior element hypertrophy on magnetic resonance imaging as well as clinical 
documentation of dynamic instability. 
 
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 pay for inpatient hospital services provided on September 26, 2022, 
to October 3, 2022, 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 A41.9 is 
supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says A41.9 is not supported in the documentation. 
 
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 principal diagnosis code A41.9, defined as sepsis, 
unspecified organism. 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 reviewer says that principal diagnosis A41.9 is not supported in the 
documentation. Our physician reviewer found the enrollee was treated for chronic, non-healing cellulitis in the 
setting of morbid obesity and immobility. There is no evidence that then enrollee had sepsis (for example, 
hypotension, hypoperfusion, organ failure). 
 
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 September 26, 2022, to October 3, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water-circulating heat pad with pump (code E0217) 
billed for dates of service December 10, 2022, to January 6, 2023. 
 
You asked the Plan to pay for code E0217. You say that this item is medically necessary based on medical 
literature. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that water circulating heat pads with pump (E0217) are 
excluded from coverage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0217 have not been met. Therefore, we decided that the Plan does not have to pay for the 
water-circulating heat pad with pump (code E0217) billed for dates of service December 10, 2022, to January 
6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service January 27, 2023, to February 1, 2023, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service January 27, 2023, to 
February 1, 2023, billed with code 99153.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for an in-lab sleep study. 
 
The Plan follows Medicare rules. Medicare rules say that sleep studies can be covered when specific criteria 
are met. 
 
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 sleep study. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee had a home sleep test study 
completed which did not show OSA. The enrollee has symptoms, but other causes should be excluded. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services beyond October 
5, 2023. 
 
You asked the Plan to pre-approve continued SNF services. The Plan denied your request. The Plan says that 
the clinical information submitted did not establish medical necessity. 
 
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 did not provide medical records or proof that medical records were 
requested for this case. We asked for medical records, but they were not provided to us. Without this 
information we cannot determine that the Plan's coverage rules support the denial in this case. Consequently, 
the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to 
pre-approve continued skilled nursing facility (SNF) services beyond October 5, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service March 16, 
2023. 
 
You asked the Plan to pay for procedure code 99497. The Plan denied your request. The Plan says payment for 
code 99497 is bundled into payment for code 99223. 
 
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 99497 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99497 billed for date of service March 16, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97116 and 97530 for date of service June 3, 
2023. 
 
You asked the Plan to pay for procedure codes 97116 and 97530. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the codes at issue 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 97116 is therapeutic procedure, 1 or more areas, each 15 
minutes; gait training (includes stair climbing). The CPT Code Manual definition of code 97530 is therapeutic 
activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), 
each 15 minutes. 
 
We find that CPT codes 97116 and 97530 are not supported in the medical record. Specifically, the codes 
definition are time-based, and the records submitted for review do not document the total time spent providing 
the services described by this code. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 97116 and 97530 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 97116 and 97530 for date of service June 3, 2023.