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

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that due to the current high burden of care and inability 
to care for the enrollee physically, medically, and financially at home, the enrollee will need to be transitioned 
to the SNF to continue recovery. The Plan denied your request. The Plan says the SNF services requested do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. 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. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary 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 epidural steroid injections. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does not reveal a recent failure to respond to four (4) weeks of noninvasive conservative care. There is no 
evidence this enrollee is being treated for acute herpes zoster refractory to conservative management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on October 25, 2022, billed 
with code G0127. 
 
You asked the Plan to pay for the podiatry services as billed. You say that the records support the services as 
billed. The Plan denied your request. The Plan says this claim should have been billed with more specific 
anatomical modifiers. 
 The Plan must follow Medicare rules. Medicare rules say that an appropriate NCCI-PTP modifier must be used 
when reporting a Column 2 code in a PTP edit pair.  
 
We looked at the file and Medicare rules. The code G0127 is a Column 2 code in relation to code 11720. 
Modifier -59 was used to indicate this was a distinct procedural service. However, the record shows that this 
service was performed on separate structures, specifically, different toes. Modifier -XS would be more 
descriptive of this situation, or the modifiers for each of the toes treated with the G0127 service. Modifier -59 
should not be used in this situation. Based on this information, we decided that Medicare rules for coverage of 
the podiatry services as billed have not been met. Therefore, we decided that the Plan does not have to pay for 
the podiatry services provided on October 25, 2022, billed with code G0127.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services (D3320, D0120, D2954, D7140, 
D0220, D0230) provided from February 9, 2021, to January 4, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services provided. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit.    
 
You have been asked to pay a 50% coinsurance for the dental services. This item/service falls within the dental 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. 
 Therefore, we decided that the Plan does not have to pay more for dental services (D3320, D0120, D2954, 
D7140, D0220, D0230) provided from February 9, 2021, to January 4, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xanax tablets. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has been using this medication for 
7 years and is benefitting. 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 Xanax tablets.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service August 30, 2022. 
 
You asked the Plan to pay for code 99223. You say that you have submitted medical records to support 
payment. The Plan denied your request. The Plan says the medical records provided do not support the billing 
of 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, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history, a 
comprehensive exam, and medical decision making of high complexity. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the only medical records you 
provided were from the cardiac catheterization procedure itself.  You have not provided any medical records from a hospital visit.  Without such records, we cannot determine if code 99223 was supported. Based on this 
information, we decided that Medicare rules for coverage of code 99223 have not been met. Therefore, we 
decided that the Plan does not have to pay for code 99223 billed for date of service August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing provided is a covered service so this 
claim should be paid. 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 provided on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95870 billed for date of service May 3, 2021. 
 
You asked the Plan to pay for procedure code 95870. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 95870 is bundled into payment for code 95868.  
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 95870 
is a column II code to column I code 95868. 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 95870 billed for date of service May 3, 2021.
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 26, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. 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 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 CDx (0242U) provided on September 29, 2021. 
 
You asked the Plan to pay for Guardant360 CDx. You say that this test was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of Guardant360 CDx 
have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 CDx (0242U) 
provided on September 29, 2021.
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 the services are medically necessary. The Plan 
denied your request. The Plan says the services you need can be provided safely in another setting such as a 
skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 enrollee does not require intensive rehabilitation services to recover from a hip 
fracture and cannot tolerate intensive therapy. Therefore, IRF criteria is not met. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an electronic knee and advanced 
foot with ankle feature. 
 
You asked the Plan to pre-approve upgraded prosthetic components. You say that the enrollee does meet 
requirement because they currently use the same foot and knee that is being denied. You say that this was 
approved previously for the enrollee. You say that everything is out of warranty and needs to be replaced. You 
also say that it needs to be replaced with same components. The Plan denied your request. The Plan says the 
requested components exceed the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded prosthetic components may be covered 
when certain criteria have been 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-approved upgraded prosthetic components. Our 
reviewer says that the requested upgraded components are not medically necessary. Our physician reviewer 
found the provided documentation indicates that the enrollee ambulates with crutches. The reviewer found that 
the documentation indicates the enrollee has significant comorbidities including shortness of breath with 
exertion. The reviewer found that these indications are not consistent with a K3 ambulator. Therefore, the reviewer found that the requested upgraded components are 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 upgraded prosthetic components have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a prosthetic leg with an electronic knee and advanced foot with ankle 
feature.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from 
September 1, 2022, to September 30, 2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the Medicare rules. We find that the home health services were not billed with a G 
code as required. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for home health services billed for 
dates of service from September 1, 2022, to September 30, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 3 acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case. 
 
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 these services. Our reviewer says that 
the requested services are medically necessary. Our physician reviewer found that the records document clear 
improvement in walking up and down stairs. This improvement has been made over time. Therefore, the 
requested services are medically reasonable and necessary. 
 
We looked at this physician's review, the file, and the Plans rules. Based on this information, we decided that 
the Plans rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve 3 acupuncture treatments.  
 
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 a genicular nerve block (64454) billed for date of service 
December 21, 2022. 
 
You asked the Plan to pay for a genicular nerve block. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met because the 
services at issue have been billed with an ineligible diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for CPT code 64454 is limited to 
specified diagnosis codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a genicular nerve block have not been met. Specifically, the case record indicates that the diagnosis 
code provided for the services at issue is M17.0, Bilateral primary osteoarthritis of knee. This code is not specified in the rules as an eligible diagnosis code for CPT code 64454. Therefore, we decided that the Plan 
does not have to pay for a genicular nerve block (64454) billed for date of service December 21, 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 requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the request for an IRF admission 
does not meet medical necessity. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95955, 95908 and 95927 billed for date of 
service March 1, 2021. 
 
You asked the Plan to pay for procedure codes 95955, 95908 and 95927. You say that these services are 
supported in the medical record. The Plan denied your request. The Plan says these services 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 95955, 95908 and 95927. Our reviewer says 
that these codes are not supported in the medical record. Our reviewer found that code 95955 is not supported, 
as in this procedure, the provider uses electroencephalographic monitoring of a patient during non-intracranial surgery like cardiac surgery or carotid stenting. This procedure cannot be verified. The procedure report does 
not support code 95908, as this is nerve conduction measure amplitude, latency/velocity, which is not 
documented in the procedure report, and therefore cannot be verified. The report also does not describe the 
services which would be reported with code 95927. In this procedure, the provider performs a short-latency 
somatosensory evoked potential study by stimulating the peripheral nerves or skin sites in the trunk or head. 
 
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 95955, 95908 and 95927 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 95955, 95908 and 95927 billed for date of 
service March 1, 2021.