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

 
We decided that the Plan does not have to pay for the intravascular ultrasound (37253 x5) and artery x-rays of 
the arm/leg (75710-59-LT) provided on March 6, 2023. 
 
You asked the Plan to pay for the intravascular ultrasound (37253 x5) and artery x-rays of the arm/leg (75710-
59-LT). You say that procedure code 37253 shows that five vessels were imaged per review of the notes. The 
Plan denied your request. The Plan says procedure code 37253 is not supported by the medical records 
submitted. The Plan also says that procedure code 75710-59-LT was denied as inclusive to the primary 
procedure 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. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 
 
In this case, the CPT Code Manual definition of code 37253 is Intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure). 
The CPT Code Manual definition of code 75710 is Angiography, extremity, unilateral, radiological supervision 
and interpretation. 
 
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 intravascular ultrasound (37253 x5) and artery x-rays of 
the arm/leg (75710-59-LT). Our reviewer says that the criteria are not met for CPT codes 37253 and 75710. 
Our reviewer found the procedure report does not include documentation of additional noncoronary vessel for 
coverage of for CPT 37253. Our reviewer also found that the procedure report describes an intervention 
performed. In this, radiology and interpretation would be included in the intervention procedure. Therefore, 
CPT 75710 is not supported. 
 
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 intravascular ultrasound (37253 x5) and artery x-rays of the arm/leg (75710-
59-LT) have not been met. Therefore, we decided that the Plan does not have to pay for the intravascular 
ultrasound (37253 x5) and artery x-rays of the arm/leg (75710-59-LT) provided on March 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation that the enrollee is unable to perform mobility-related 
activities of daily living (MRADLs) in the home or community without a power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
records in this case document that the enrollee is ambulating short distances with a cane or walker. There is no 
documentation that the enrollee's mobility deficit cannot be helped by the use of a walker, cane, or manual 
wheelchair. The enrollee is self-propelling a manual ultra-lightweight wheelchair.  
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J1817 billed for date of service March 6, 
2023. 
 
You asked the Plan to pay for the billed service. The Plan denied your request. The Plan says there is a more 
appropriate code that should be used.  
 
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 J1817 is insulin for administration through dme (i.e., 
insulin pump) per 50 units. 
 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 billed service. Our reviewer found that code J1817 is not 
supported by the medical record. The record does not say that the insulin was administered via DME. There is a 
more appropriate code to report the insulin administered.  
 
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 billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code J1817 billed for date of service March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and annual wellness visit provided on 
February 22, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for the physician services. You say that payment should be made for this service. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
Although the enrollees plan has a Point of Service (POS) benefit, authorization is still required to see any out-
of-network providers. The provider in this case is not a network provider with the Plan. The Plan had network 
providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve 
the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the office visit and annual wellness visit provided on February 
22, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transplant-related travel and lodging expenses provided on 
May 4, 2023. 
 
You asked the Plan to pay for transplant-related travel and lodging expenses. You say that you are still 
travelling for appointments. The Plan denied your request. The Plan says this date of service is more than 1 
year after your transplant; therefore, the travel and lodging expenses are not covered by the Plan. 
 The Plan must follow Medicare rules. Medicare rules say that health plans must offer reasonable transportation 
and lodging when an enrollee receives covered transplant services at a distant location. Your contract with the 
Plan states that the Plan covers transplant-related travel and lodging up to 1 year after the date of the transplant. 
 
We looked at the file and Medicare rules. You received your covered transplant on April 18, 2022. These 
expenses were incurred on May 4, 2023; therefore, the travel and lodging expenses are more than 1 year after 
your covered transplant which is outside of the period of care for reimbursement. Based on this information, we 
decided that Medicare rules for coverage of transplant-related travel and lodging expenses have not been met. 
Therefore, we decided that the Plan does not have to pay for transplant-related travel and lodging expenses 
provided on May 4, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic radiology services provided on March 20, 2023. 
 
You asked the Plan to pay for the diagnostic radiology services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that the claim for the related service has not been 
received or allowed. 
 
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. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for diagnostic radiology services 
provided on March 20, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service April 1, 
2023, to April 30, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the code covers all necessary services. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service April 1, 2023, to April 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial hospitalization. 
 
You asked the Plan to pre-approve a partial hospitalization. You say that the enrollee presents with a diagnosis 
of severe, recurrent major depression with psychotic symptoms. You also say that the need for treatment to 
stabilize affective symptoms and avoid acute hospitalization is recognized. The Plan denied your request. The 
Plan says based on the information provided, after completing inpatient treatment, with resolution of risk 
symptoms, the enrollee can be safely managed on an outpatient basis with increased frequency of visits with 
their psychiatrist. The Plan also says the documented clinical findings do not justify the level of care requested. 
 
The Plan follows Medicare rules. Medicare rules say that continued treatment in order to maintain a stable 
psychiatric condition or functional level requires evidence that less intensive treatment options (e.g., intensive 
outpatient, psychosocial, day treatment, and/or other community supports) cannot provide the level of support 
necessary to maintain the patient and to prevent hospitalization. 
 
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 partial hospitalization. Our reviewer 
says that the health plans denial of continued partial hospitalization treatment appears appropriate. Our 
physician reviewer found this enrollee does not appear to require partial hospitalization treatment. They were 
not showing any severity of psychological or psychiatric illness. Our reviewer found that this enrollee does not 
meet the criteria for treatment at partial hospitalization level of care and could be treated in a lesser restrictive 
setting as she were not showing any suicidal or homicidal ideation and was not showing any psychosis or 
aggressive behaviors. 
 
 
 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 partial hospitalization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a partial hospitalization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2331, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no need to control the power options through the joystick. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provided records document that the enrollee has 4/5 right upper extremity grip strength 
and is independent with lower body dressing thus indicating he has adequate upper extremity strength and 
function to operate the wheelchair's power options with their own switches and thus the controller, harness and 
electronic connection (E2311, E2313, E2331, E2377) to control the chair's power options with a joystick do not 
meet criteria for coverage.  The provided records from the enrollee's treating practitioner do not clearly 
document the need for an attendant control (E2313); the documentation from physical therapy seems to 
indicate that the attendant control is more for use "in the case of future cognitive decline" as opposed to a 
current need, especially since the patient-controlled drive system is being covered.  
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2331, E2377).
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 can receive medical management of your current 
needs and reduce your risk of returning to the hospital. The Plan denied your request. The Plan says you do not 
meet the requirements for admission to an IRF. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 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 without relief. The Plan denied your request. The Plan says medical studies haven't 
proven this service is helpful for the treatment of the enrollee's health problem.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only modic endplate 
changes without facet degenerative joint disease (DJD) or foraminal stenosis. The cause of pain is not clear. 
Thus, this service is not covered.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Inspire surgical procedure, including hypoglossal 
nerve stimulator placement. 
 You asked the Plan to pre-approve the Inspire procedure. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this procedure is not covered when a sleep study shows 
the apnea-hyponea index more than 65 events per hour. 
 
The Plan follows Medicare rules. Medicare rules say that hypoglossal nerve neurostimulation is considered 
medically reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea when an 
apnea-hypopnea index is 15 to 65 events per hour. 
 
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 Inspire procedure. Our reviewer 
says that the requested Inspire procedure is not medically necessary. Our physician reviewer found the 
provided documentation indicates that you have moderate to severe obstructive sleep apnea with an apnea-
hypopnea index of 84.2 events per hour documented in 2021. Therefore, the reviewer found that the requested 
Inspire procedure is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Inspire procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Inspire surgical procedure, including hypoglossal nerve stimulator placement.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31231 billed for date of service March 3, 
2023. 
 
You asked the Plan to pay for procedure code 31231. You say that this service is supported as billed. The Plan 
denied your request. The Plan says this code is 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. 
 
In this case, the CPT Code Manual definition of code 31231 is nasal endoscopy, diagnostic, unilateral or 
bilateral (separate procedure). 
 
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 code 31231. Our reviewer says that this code is 
not supported in the records provided. Our reviewer found this service cannot be found in the procedure report, and therefore cannot be verified. 
 
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 code 31231 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 31231 billed for date of service March 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Apollo endoluminal overstitch procedure. 
 
You asked the Plan to pre-approve the Apollo procedure. You say that this procedure would restore the 
restrictive components of the original gastric bypass by limiting the volume of food intake and slowing the 
emptying of food from the stomach to the small bowel. The Plan denied your request. The Plan says this 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 the Apollo procedure. Our reviewer 
says that the requested Apollo procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not indicate the enrollee's body mass index (BMI) 
quantifies them as class 2 or class 3 obesity. The reviewer found that the enrollee has had this procedure previously without sustained efficacy. The treatment remains investigational for treatment of weight recurrence 
given the lack of published high level studies documenting durable more than 5 years efficacy. Therefore, the 
requested Apollo procedure is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Apollo procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Apollo endoluminal overstitch procedure.