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

 
We decided that the Plan does not have to pre-approve  a Vertiflex device (22869, 22870). 
 
You asked the Plan to pre-approve  a Vertiflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex device. 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 compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion 
interspinous spacer at L3-5, in this case, is not medically reasonable or necessary.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve  a Vertiflex device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our physician reviewer 
found that the record does not indicate the enrollee is on insulin or has a history of problematic hypoglycemia. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on June 21, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on June 21, 2023.
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 enrollee still requires hospital level of care due to 
recent heart surgery. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting 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 the enrollee's 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. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
January 13, 2023. 
 
You asked the Plan to pay for hospital discharge day management (99239). You say that the attached reports 
should be reviewed, and the claim reprocessed according to the contract. The Plan denied your request. The 
Plan says the code at issue is 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 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the code definition is 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 hospital 
discharge day management (99239) have not been met. Therefore, we decided that the Plan does not have to 
pay for hospital discharge day management (99239) provided on January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D0120, D1110) 
provided on July 2, 2023, to July 6, 2023. 
 
You asked the Plan to pay 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 your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 16, 2023. 
Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D0120, 
D1110) provided on July 2, 2023, to July 6, 2023.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services provided on March 3, 2023, billed with procedure code 93306-TC.

You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does not support the billed code.

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 93306 is echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography.

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 testing services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found in this case, there is a more specific code to report for service documented.

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 testing services provided have not been met. Therefore, we decided that the Plan does not have to pay for testing services provided on March 3, 2023, billed with procedure code 93306-TC.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual therapy and chiropractic manipulative treatment 
provided by a chiropractor on April 24, 2023. 
 
You asked the Plan to pay for manual therapy. You say that you are seeking reimbursement or an adjustment 
for the manual therapy. The Plan denied your request. The Plan says he only covered chiropractic service is 
manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for manual therapy and chiropractic manipulative treatment provided by a 
chiropractor on April 24, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), expandable 
controller (E2377), and foot plate/bracket assembly (K0108 x2). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, and foot 
plate/bracket assembly. You say that without the power wheelchair, the enrollee is at risk of compounding 
health issues. You also say that this request is completely reasonable and medically necessary. The Plan denied 
your request. The Plan says that although there are three requested power options (tilt, recline and elevating leg 
rests), there is not a medical need to control these power options through the joystick. The Plan also says the 
foot plate/bracket assembly coded as K0108, and these parts are miscoded. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an electronic connection, harness, 
expandable controller, and foot plate/bracket assembly. Our reviewer says that the requested items/services are 
considered medically reasonable and necessary in this case. Our physician reviewer found the complexity of 
the enrollees seating and positioning needs necessitates a more complex group 3 power wheelchair base. Our 
reviewer found that the expandable controller with harness and electronic connection are necessary to operate 
the group 3 power wheelchair base and the three power options via a joystick. These components are required 
to operate 3 or more power options on a group 3 power wheelchair. Our physician reviewer also found that the 
foot plate/bracket is also needed to support the enrollees lower extremities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, expandable controller, and foot plate/bracket 
assembly have been met. Therefore, we decided that the Plan has to pre-approve an electronic connection 
(E2311), harness (E2313), expandable controller (E2377), and foot plate/bracket assembly (K0108 x2).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve for multiple sleep latency test (95805). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says a multiple sleep latency test (MSLT) is used to test patients with sign of narcolepsy. The Plan states these signs include excessive daytime sleepiness, as well as cataplexy, sleep 
paralysis, or vivid dreams. the Plan states the enrollee's doctor did not say that they have any of these signs. 
 
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 services. Our physician reviewer 
found the review indicates that the records sent in does not show that the enrollee exhibits one or more 
symptoms of narcolepsy [for example, cataplexy (sudden and transient loss of muscle tone, often triggered by 
emotions such as laughing or crying; sleep paralysis; regularly occurring hypnagogic hallucinations; or 
regularly occurring hypnopompic hallucinations]. Furthermore, the records sent in does not show that other 
causes of excessive sleepiness have been ruled out or treated when possible. The review indicates that the 
enrollee does not meet criteria for coverage. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve for multiple sleep latency test (95805).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on March 27, 2023. 
 
You asked the Plan to pay for the imaging services. 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 the place of service (POS) code to be used by the 
physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-
face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services have not been met. Specifically, this claim was billed with the office setting 
POS code. The records do not support that the imaging services were provided in an office setting. Therefore, 
we decided that the Plan does not have to pay for the imaging services provided on March 27, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for imaging services provided on November 21, 2022. 
 
You asked the Plan to pay for imaging services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that precertification was not obtained for service. 
 
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 denied payment for these services on the basis that precertification was 
not obtained. However, this Plan is a preferred provider organization (PPO) format plan with out-of-network 
benefits, and prior authorization is not mandatory for outpatient diagnostic tests. Therefore, the Plan has not 
shown that its decision to deny payment for these services is correct. Therefore, we decided that the Plan has to 
pay for imaging services provided on November 21, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 13, 2023. 
 
You asked the Plan to pay for the services. 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 R53.1 has an Excludes1 note in relation to M62.81. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for 
the services provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nephrology services coded as 90999, A4657, J1644, and 
J1756 billed for dates of service February 1, 2023, through February 3, 2023. 
 
You asked the Plan to pay for the nephrology services. You say that the nephrology services should be paid as 
billed because the primary insurance's explanation of benefits (EOB) for these services is included in the 
casefile. The Plan denied your request. The Plan says the nephrology services are denied because the enrollee 
had another insurance as primary on February 1, 2023, through February 3, 2023, and no EOB from the 
primary insurer was received for these dates of service.  
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill for the claim dated February 1, 2023, through February 3, 2023, to the primary insurer 
on multiple occasions. We confirmed that the primary insurance carriers EOB in the casefile is for a different 
claim with dates of service in January 2023, rather than the claim and dates of service in question in this case. 
As the secondary insurer, the Plan cannot be held responsible for the nephrology services until the primary 
insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the 
nephrology services coded as 90999, A4657, J1644, and J1756 billed for dates of service February 1, 2023, 
through February 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics, shoe inserts.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics, shoe inserts are medically necessary. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics, shoe inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99212 billed for date of service August 1, 
2023. 
 You asked the Plan to pay for procedure code 99212. You say that a cancel claim was submitted. The Plan 
denied your request. The Plan says payment for code 99212 is bundled into payment for code 99213. 
 
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 99212 is a column II code to column I code 99213. Code 99212 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 99212 
billed for date of service August 1, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (87481) provided on April 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code is 
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 87481 is "Infectious agent detection by nucleic acid 
(DNA or RNA); Candida species, amplified probe technique". 
 
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 use of code 87481 is 
supported by the records provided. Our reviewer found that this is an infection panel of a urine sample. This 
was ordered as the enrollee has recurrent urinary tract infections, the lab results show that an infection was 
detected. 
 
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 has to pay 
for the lab services (87481) provided on April 18, 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.