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

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service January 13, 
2023. 
 You asked the Plan to pay for procedure code 88341. You say that this service was reported correctly and is 
supported in the medical record. The Plan denied your request. The Plan says payment for code 88341 is 
bundled into payment for code 88360. 
 
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 88341 
is a column II code to column I code 88360. 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 88341 billed for date of service January 13, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient evaluation and management (EM) services 
provided on December 15, 2022, billed with code 99213. 
 
You asked the Plan to pay for the EM services. You say that this visit should be paid. The Plan denied your 
request. The Plan says this was a follow-up visit for the prior prostatectomy and was not billed correctly to 
allow separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report an unrelated evaluation and 
management service by same physician during a postoperative period, modifier -24 must be used.  
 We looked at the file and Medicare rules. In this case, the EM service was provided by a provider in the same 
billing group as the provider who rendered the prostatectomy. Separate payment for this visit would require the 
use of modifier -24. Based on this information, we decided that Medicare rules for coverage of the EM services 
have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient evaluation and 
management (EM) services provided on December 15, 2022, billed with code 99213.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided from November 17, 
2022, through November 29, 2022. 
 
You asked the Plan to pay for critical care services (99291). The Plan denied your request. The Plan says the 
medical records submitted do not support a critical care visit of 30-74 minutes was performed. 
  
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the medical records do not 
document critical care services of 30 to 74 minutes was performed as required by the procedure code billed. 
Based on this information, we decided that Medicare rules for coverage of critical care services (99291) have 
not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) 
provided from November 17, 2022, through November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and additional 
records have been submitted for reconsideration. The Plan denied your request. The Plan says the records do 
not show failure of BiPAP. The enrollee's doctor has requested a NIV in ventilation mode, which could be met 
by a BiPAP. The request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records indicate the 
ventilator is a Trilogy device with ventilation mode settings that appear to indicate that the home ventilator is 
being requested for use in average volume assured pressure support (AVAPS) mode with auto-EPAP (AE) 
which could be provided by a BiPAP device with AVAPS and a back-up rate. Provided records do not 
document trial and failure of a BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage 
Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for 
conditions described in this RAD policy will be denied as not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the skull base to mid-thigh. 
 
You asked the Plan to pre-approve the PET scan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says in this case, a PET scan is not covered for surveillance imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the requested PET scan is not medically necessary. Our physician reviewer found the enrollee was treated for 
small cell lung cancer in 2018 and is being followed after completion of therapy. A PET scan is specifically 
stated as not recommended in the National Comprehensive Cancer Network guidelines. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan of the skull base to mid-thigh.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept intraosseous nerve ablation. 
 
You asked the Plan to pre-approve intracept intraosseous nerve ablation. You say that intracept intraosseous 
nerve ablation is medically necessary. The Plan denied your request. The Plan says the requested intracept 
intraosseous nerve ablation is experimental. 
 
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 intracept intraosseous nerve ablation. 
Our reviewer says that the requested intracept intraosseous nerve ablation is not considered medically 
reasonable and necessary. Our physician reviewer found that the intracept procedure targets the basivertebral 
nerve for the relief of chronic vertebrogenic low back pain. Medicare guidelines consider this type of system 
unproven and not medically necessary. Large well-designed studies in the peer review scientific literature comparing stand-alone use of intracept device to established surgical decompression are needed. Published 
studies do not demonstrate any long-term health outcome advantage with the use of intracept as an alternative 
to standard surgical treatment. The review has determined that the requested intraosseous nerve ablation 
(intracept procedure) is not medically reasonable or necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intracept intraosseous nerve ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve intracept intraosseous nerve ablation.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the Plan asserts you are at baseline but provides no objective evidence. You are 
clearly functionally impaired, and it is not clear whether this is a chronic situation or an acute decline. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device (E2310), a headrest 
(E0955), and the headrest hardware (E1028). 
 
You asked the Plan to pre-approve a connection device, headrest, and hardware. You say that the requested 
accessories are medically necessary. The Plan denied your request. The Plan says that the requested items are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an electronic connection device is covered when it is 
necessary to control the power options through the joystick. The rules also that a headrest is covered when the 
enrollee has significant postural asymmetries. 
 
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 connection device, headrest, and 
hardware. Our reviewer says that these items are not medically necessary. Our physician reviewer found that 
the enrollee had adequate strength to manage the standard power drive controls. The enrollee also does not 
have poor head control. 
 
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 connection device, headrest, and hardware have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection device (E2310), a headrest 
(E0955), and the headrest hardware (E1028).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second home sleep test (HST) with a type III portable 
monitor (G0399) provided on December 29, 2022. 
 
You asked the Plan to pay for the second HST. You say that you are certain that the denial of your sleep study 
is not accurate because you did not have any other studies recently. You also say that you were unaware the 
service was not covered. The Plan denied your request. The Plan says this request is not medically necessary 
because your records do not show why you needed a second home sleep study 2 days after the initial sleep 
study that established the diagnosis. 
 
The Plan follows Medicare rules. Medicare rules say that if more than one HST session is performed for 
suspected OSA, persuasive medical evidence justifying the medical necessity for the additional tests will be 
required. 
 
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 second HST. Our reviewer says that the 
second home sleep test was not medically necessary. Our physician reviewer found you underwent a home 
sleep test on December 27, 2022, that showed severe obstructive sleep apnea. The duration and recording 
quality of the test were judged to be adequate.  Our reviewer found that another home sleep test was performed 
the night of December 29, 2022. Our physician reviewer also found that the medical records provide no 
explanation or justification for the second test. 
 
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 second HST have not been met. Therefore, we decided that the Plan does 
not have to pay for the second home sleep test (HST) with a type III portable monitor (G0399) provided on 
December 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 18, 2022, to 
August 16, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services were medically 
necessary and should be paid. The Plan denied your request. The Plan says the claim has not been billed with 
the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 18, 2022, to August 
16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6750), a pontic (D6240) and a core 
build-up (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you assumed this was a covered benefit. 
The Plan denied your request. The Plan says these services are not covered by the Plan's dental benefits. 
 
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. Therefore, we decided that the Plan does not have to pre-approve a 
retainer crown (D6750), a pontic (D6240) and a core build-up (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device was specifically prescribed to 
help manage your respiratory needs at home. The Plan denied your request. The Plan says the request for a 
home mechanical ventilator set in AC mode with very low tidal volumes that could be delivered by BiPAP is 
not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have a a diagnosis of severe 
chronic obstructive pulmonary disease but do not fully support the diagnosis of chronic respiratory failure.  
Provided records document that the home ventilator is being requested for use with very low set tidal volumes 
(150 to 200 mL) which could be provided by a BiPAP device with average volume assured pressure support 
(AVAPS) and a back-up rate. Provided records do not document trial and failure of a BiPAP device with 
AVAPS and a back-up rate. As stated in the Local Coverage Determination (L33800): "Claims for ventilators 
used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as 
not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee. 
 
You asked the Plan to pre-approve a microprocessor knee. You say that the stumble recovery feature is 
important to reduce the risk of falls. You say that the enrollee is a K3 ambulator. You also say that the 
requested microprocessor knee is medically necessary for the enrollee. The Plan denied your request. The Plan 
says the requested K3 microprocessor knee is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a microprocessor knee. Our reviewer 
says that the requested microprocessor knee is not medically necessary. Our physician reviewer found the 
physician documentation does not support why the enrollee requires a microprocessor knee over a mechanical 
K3 knee for the enrollee's activities and function. The requested microprocessor knee exceeds the enrollee's 
needs. Therefore, the reviewer found that the requested microprocessor knee 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 a microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01230-QZ-P2 x 88 and 99100) 
provided on June 14, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed and are not supported by the records. 
 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 01230 is anesthesia for open procedures involving upper 
two-thirds of femur; not otherwise specified. 
 
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 anesthesia services. Our reviewer found the record does 
not support 88 units of 01230; the time frame documented falls short of this and the practitioner's time is not 
documented. Furthermore, 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. 
 
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 anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services (01230-QZ-P2 x 88 and 99100) provided on June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the speech generating device (E2510) and mounting system (E2512) 
provided on October 31, 2022. 
 
You asked the Plan to pay for the durable medical equipment (DME). You say that the items should be 
covered. The Plan denied your request. The Plan says that the billed supply codes cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity. 
 
The record contains a valid physician order, proof of delivery, or relevant medical records which support 
medical necessity for the supplies provided in this case. Therefore, we decided that the Plan has to pay for the 
speech generating device (E2510) and mounting system (E2512) provided on October 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.