Persius/hicric huggingface dataset:
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 genicular artery embolization. 
 
You asked the Plan to pre-approve the outpatient service. You say that the enrollee has symptomatic 
osteoarthritis in both knees with significant functional impairment despite appropriate treatment. You say that 
this procedure is minimally invasive and may be of significant benefit to the enrollee to reduce their symptoms. 
The Plan denied your request. The Plan says this procedure to treat knee osteoarthritis is unproven and 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 outpatient service. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. While the studies are noted to be 
promising, further studies/research is needed to corroborate that geniculate artery embolization is as good as or 
better than standard treatments for knee osteoarthritis. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
genicular artery embolization 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 outpatient service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular artery embolization.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with high gold content crown on tooth 14 
(D2750). 
 
You asked the Plan to pre-approve white glass with high gold content crown on tooth 14. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has 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 crowns 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 white glass with high gold content 
crown on tooth 14. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the radiographs provided were not of diagnostic quality to determine if a replacement crown is 
warranted. There was no narrative indicating why a replacement crown is necessary. 
 
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 white glass with high gold content crown on tooth 14 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve white glass with high gold content crown on 
tooth 14 (D2750).
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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 medical record does not indicate that the enrollee requires services that the 
enrollee is not currently receiving but that would be available at the LTACH facility.  The elements of the 
coverage rules are not satisfied.  The requested service cannot be recommended. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services billed with code 27880-RT-80 for 
date of service June 19, 2022. 
 You asked the Plan to pay for the surgical assistant services. You say that an assistant surgeon was used for this 
procedure and was not paid. You have provided medical records to support payment. The Plan denied your 
request. The Plan says this claim was not billed with the correct modifier and that this procedure does not pay 
for an assistant at surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that assistant-at-surgery services are only covered for 
certain procedures.  In addition, the rules say that surgical assistant services provided by a physician should be 
billed with modifiers -80, -81, or -82. The AS modifier is to be used for assistants-at-surgery who are physician 
assistants, nurse practitioners and clinical nurse specialists. 
 
In this case, the Plan denied your request for payment for two reasons.  First, the Plan denied your request 
stating that the procedure in dispute (i.e., 27880) does not permit coverage of assistant-at-surgery services.  We 
disagree.  The Medicare Physician Fee Schedule clearly lists this code in 2022 as having an assistant surgery 
indicator of 2, meaning that assistant-at-surgery services are covered for this procedure.  So, we disagree with 
this rationale offered by the Plan.  However, the Plan also denied your request for payment because you billed 
with an incorrect modifier. We agree with this rationale.  Specifically, you billed this code with modifier 80.  
Modifier 80 is only to be used to indicate that assistant-at-surgery services were provided by a physician.  In 
this case, the records show that the actual assistant-at-surgery services were provided by a Physicians 
Assistant (PA).  According to Medicare rules, assistant-at-surgery services provided by a PA should be billed 
with the AS modifier, not the 80 modifier.  That is why this claim cannot be paid as billed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical assistant services have not been met. Therefore, we decided that the Plan does not have 
to pay for surgical assistant services billed with code 27880-RT-80 for date of service June 19, 2022.
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, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment with no relief. The Plan denied your request. The Plan says the records do not show that 
the basivertebral nerve is the cause of the enrollee's pain or that another cause, such as the enrollee's image 
demonstrated spinal stenosis and S1 nerve compression, are not the primary drivers for the enrollee's pain.  
The Plan follows Medicare rules. Medicare rules say that thermal destruction of the intraosseous BVN will be 
considered medically reasonable and necessary for the treatment of chronic low back pain in patients with the 
absence of non-vertebrogenic pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
 
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 medically necessary. Our physician reviewer found the 
provided documentation does not indicate Modic changes without facet degenerative joint disease or foraminal 
stenosis. The reviewer also found that there is no clear cause for the enrollee's pain. Therefore, the reviewer 
found that the requested Intracept procedure is not medically reasonable or necessary in this case. 
 
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, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0157) provided on July 15, 2022 to 
July 20, 2022. 
 
You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 code G0157 is not supported in the medical record. Specifically, the records did not include a 
plan of care. Additional records were requested by the plan and they were not provided. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services (G0157) provided on July 
15, 2022 to July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OneOme RightMed Comprehensive Test (RightMed Test 
and MTHFR test) provided on February 13, 2023. 
 
You asked the Plan to pay for the OneOme RightMed Comprehensive Test. You say that the enrollee's 
physician has determined this testing to be medically necessary.  The Plan denied your request. The Plan says 
the records do not show a multigene panel is necessary or what other CPIC A or B medications the provider is 
considering. In addition, MTHFR is not considered to be medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter 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 pay for the OneOme RightMed Comprehensive 
Test. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
MTHFR is not considered clinically relevant to this specific clinical situation and was not supported in the 
documentation. Also, the specific medications being considered were not listed in the documentation, nor 
reasoning as to why multiple genes were needed to be tested for this patient. Therefore, without sufficient 
support made for this request, the OneOme RightMed Comprehensive Test will be considered not medically 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the OneOme RightMed Comprehensive Test have not been met. Therefore, we 
decided that the Plan does not have to pay for the OneOme RightMed Comprehensive Test (RightMed Test and 
MTHFR test) provided on February 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service January 23, 
2023, to February 21, 2023. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 23, 2023. The NOA was not received by the Plan until April 26, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for 
date of service January 23, 2023, to February 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37224, 75710 and 76937 billed for date of 
service April 14, 2022. 
 
You asked the Plan to pay for procedure codes 37224, 75710 and 76937. You say that these services were 
reported appropriately for separate billing. The Plan denied your request. The Plan says the service at issue was 
not billed with the required modifier to allow separate payment within the global surgery period. Although 
code 37224 was billed with modifier 78, it is not appropriate to report this modifier with a non-operating room 
place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79. Another exception is an unplanned return trip to the 
operating room, which requires modifier -78. 
 
We looked at the file and Medicare rules. The services at issue are within the global surgery period of code 
35556 provided on March 3, 2022. We find that codes 75710 and 76937 may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. In addition, although modifier -78 was 
used with code 37224, the records do not support that this modifier was used appropriately. Specifically, this 
modifier is defined as a return trip to an operating room. However, this claim was submitted with a place of 
service (POS) code which indicates that these services were performed in an office setting. An office does not 
meet the definition of an operating room. As such, the billing rules for these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 37224, 75710 and 76937 billed 
for date of service April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on November 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and was 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 November 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pioglitazone-metformin. 
 
You asked the Plan to pre-approve the medication. You say that this was medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve pioglitazone-metformin.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 2, 2022. 
 
You asked the Plan to pay for the medical services. You say that you billed this claim with payable diagnoses. 
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 R29.6 has an Excludes1 note in relation to R26.2. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on February 2, 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 it is medically necessary. The Plan denied your 
request. The Plan says you 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 20, 2022, to 
November 9, 2022. 
 You asked the Plan to pay for the home health services. You say that you initially submitted a Request for 
Anticipated Payment in error, The Plan denied your request. The Plan says the NOA was not received timely. 
As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 20, 2022. The NOA was not received by the Plan until December 
15, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 20, 2022, to November 9, 2022.