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

 
We decided that the Plan does not have to pay for the open implantation of cranial nerve neurostimulator 
electrode array and pulse generator (64568) provided on May 24, 2023. 
 
You asked the Plan to pay for the surgical service. You say that the enrollee's past medical history includes 
medically refractory epilepsy. You say that this severely impacts the quality of their life and has caused 
injuries. You say that this has prevented the enrollee from being gainfully employed. You also say that this was 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not have a 
diagnosis of medical refractory seizures. The Plan also says the enrollee is not enrolled in a clinical trial for 
evidence development. 
 
The Plan follows Medicare rules. Medicare rules say that effective for services performed on or after July 1, 
1999, vagus nerve stimulation (VNS) is reasonable and necessary for patients with medically refractory partial 
onset seizures for whom surgery is not recommended or for whom surgery has failed. 
 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 surgical service. Our reviewer says that 
the open implantation of cranial nerve neurostimulator electrode array and pulse generator was not medically 
necessary. Our physician reviewer found the provided records in this case do not document a diagnosis of 
medically refractory partial onset seizures. The reviewer also found that the records in this case do not 
document the enrollee is not a candidate for surgery or has had a failed surgery, per the NCD. Therefore, the 
reviewer found that the open implantation of cranial nerve neurostimulator electrode array and pulse generator 
was 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 surgical service have not been met. Therefore, we decided that the Plan does 
not have to pay for the open implantation of cranial nerve neurostimulator electrode array and pulse generator 
(64568) provided on May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (K0008). 
 
You asked the Plan to pre-approve the wheelchair. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair (K0008) is covered for the 
indications established in the applicable LCD. 
 
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 manual wheelchair is not medically reasonable and necessary. Our physician reviewer found that 
the provided records do not support that the enrollee has sufficient upper extremity to operate a manual 
wheelchair, and the records do not document that the enrollee's physical and/or functional deficits cannot be 
met using one of the standard manual wheelchair bases plus an appropriate combination of wheelchair seating 
systems, cushions, options, or accessories, as required by the LCD. 
 
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 manual wheelchair (K0008).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous nerve ablations. 
 
You asked the Plan to pre-approve intraosseous nerve ablations. You say that it is medically necessary. The 
Plan denied your request. The Plan says it 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 intraosseous nerve ablations. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the intracept procedure is experimental for back pain. There is no magnetic 
resonance imaging (MRI) showing only modic changes without facet degenerative join disease or stenosis. The 
cause of pain is not clear.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraosseous nerve ablations have not been met. Therefore, we decided that the 
Plan does not have to pre-approve intraosseous nerve ablations.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 12, 2021. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until January 5, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
July 13, 2023, and billed with codes 87798, 87481, and 87150. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on July 13, 2023, and billed with codes 87798, 87481, and 87150.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 93880, 93923, 93970, and 93978 rendered on April 6, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
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 
the denied codes is: 
 
CPT 93880: 
 
Duplex scan of extracranial arteries; complete bilateral study 
 
CPT 93923: 
 
Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, 
for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries 
plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 
or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus 
segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and 
anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more 
levels), or single level study with provocative functional maneuvers (eg, measurements with postural 
provocative tests, or measurements with reactive hyperemia) 
 
CPT 93970: 
 
Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral 
study 
 
CPT 93978: 
 
Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study 
 
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 services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee had multiple vascular 
ultrasound studies done on 4/6/23. A review of the chart notes show that each of the denied exams was done on 
this date, and interpreted later. Each of these exams was well documented and complete. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure codes 93880, 93923, 93970, and 93978 rendered on April 6, 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 99152 billed for date of service May 12, 
2023. 
 You asked the Plan to pay for procedure code 99152. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for procedure code 99152 is bundled into 
payment for code 45378. 
 
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 99152 is a column II code to column I code 45378; however, 99152 
was billed with a modifier.  
 
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 99152. Our reviewer says that procedure 
code 99152 does not meet criteria for payment. Our reviewer found that procedure code 99152 is not supported 
by the medical record. The record states that an endoscopy was performed. There is a more specific code to 
report moderate sedation for endoscopy services. 
 
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 99152 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99152 billed for date of service May 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 20, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for provider delivered care management (PDCM) provided on 
September 20, 2022. 
 
You asked the Plan to pay for PDCM. You say that you were not told that you were being charged for this 
service and if the provider knew it was not covered, they should have told you. The Plan denied your request. 
The Plan says this member is enrolled in a retirement plan sponsored by your former employer group, who is 
listed as a PDCM excluded group. 
 
The Plan contract says if you get services that are excluded (not covered), you must pay for them yourself. 
 
We looked at the file and the Plans rules. The file shows that you are enrolled in a retirement plan sponsored 
by your former employer group, who is listed as a PDCM excluded group. Based on this information, we 
decided that the Plans rules for coverage of PDCM have not been met. Therefore, we decided that the Plan 
does not have to pay for PDCM provided on September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral L4-5 and L5-S1 transforaminal epidural 
injection. 
 
You asked the Plan to pre-approve transforaminal epidural injection. You say that the enrollee would have pain 
relief with these injections. The Plan denied your request. The Plan says there is a lack of an imaging study that 
shows narrowing of the spine due to a ruptured spine disc, a bone spur, and/or severe wear and tear on the discs 
in the spine. 
 
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 transforaminal epidural injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the magnetic resonance imaging (MRI) does not show severe neural compression and physical exam does not show corresponding radiculopathy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transforaminal epidural injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a bilateral L4-5 and L5-S1 transforaminal epidural injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve subcutaneous cardiac rhythm monitor. 
 
You asked the Plan to pre-approve subcutaneous cardiac rhythm monitor. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says it 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 subcutaneous cardiac rhythm monitor. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee with no cryptogenic cerebral vascular accident (CVA), or 
recent Syncope of uncertain etiology does not meet the criteria for implantation of subcutaneous heart 
monitoring. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subcutaneous cardiac rhythm monitor have not been met. Therefore, we decided 
that the Plan does not have to pre-approve subcutaneous cardiac rhythm monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on August 23, 2021, 
to August 28, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that A41.9 
and J18.9 are supported in the record, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says A41.9 and J18.9 are not supported in the record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, defined as sepsis, 
unspecified organism, and secondary diagnosis code J18.9, defined as pneumonia, unspecified organism. 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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that principal diagnosis A41.9 and secondary diagnosis J18.9 are not 
supported in the documentation. Our physician reviewer found the enrollee was hospitalized due to a recurrent 
fall and back pain. They were found to have bacteriuria and were treated for a urinary tract infection (UTI). The 
enrollee had recently been diagnosed with lung cancer. Chest imaging showed no acute changes. Coughing and 
wheezing appear to have been attributed to chronic obstructive pulmonary disease (COPD). There is no 
evidence that the enrollee had pneumonia. There is no evidence that the enrollee had sepsis (for example, 
hypotension, hypoperfusion, organ failure).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 23, 2021, to August 28, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve the continuation of SNF services after November 4, 2023. 
 
You asked the Plan pre-approve the continuation of SNF services after November 4, 2023. You say that the 
wound care providers have confirmed that the enrollee's wound will continue to require the daily dressing 
changes and wound care they provide beyond the November 4, 2023, benefit expiration date. Additionally, you 
say the enrollee has gotten physically weaker and now needs more assistance to sit and stand. The Plan denied 
your request. The Plan says as of November 4, 2023, the enrollee will have been in the SNF setting for 100 
days. 
 
The Plan must follow Medicare rules.  
 
The file shows that the enrollee will have received 100 days of SNF care during the benefit period from  
July 27, 2023, to November 4, 2023. The Plan will have covered 100 days of SNF care.  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have pre-approve the continuation of SNF services after November 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral genicular nerve blocks and radiofrequency 
ablation (RFA). 
 
You asked the Plan to pre-approve the outpatient procedures. You say that the enrollee has tried and failed 
conservative therapies. The Plan denied your request. The Plan says these services are considered experimental 
and therefore are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the outpatient procedures. Our reviewer 
says that the requested bilateral nerve blocks and RFA are not considered medically reasonable and necessary 
in this case. Our physician reviewer found this is considered experimental therapy as it is the subject of 
ongoing clinical trials. Therefore, the reviewer found that the requested nerve blocks and RFA are deemed not medically 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 the outpatient procedures have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bilateral genicular nerve blocks and radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Grafix Prime skin substitute and application. 
 
You asked the Plan to pre-approve Grafix Prime. You say that the enrollee does not have to complete an A1c. 
You say that the enrollee is a smoker and has been counseled on the impact of smoking and the wound healing 
process. The Plan denied your request. The Plan says the notes did not show that the enrollee has a chronic 
venous ulcer. The Plan says there is no evidence of any no leg ultrasound testing to show adequate circulation, 
and the enrollee continues to smoke. The Plan also says that the requested treatment is not medically 
reasonable or 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 Grafix Prime. Our reviewer says that 
the requested skin substitute and application are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records do not include documentation of size of the venous 
ulcer since May 31, 2023, to show it is not healing by standard treatments (cleaning and debriding). The 
records submitted also do not include documentation that the enrollee has adequate glycemic control if a 
diabetic (HbA1c < 12%) or if there has been smoking cessation if an active smoker. Therefore, the reviewer 
found that the requested skin substitute and application 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 Grafix Prime have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Grafix Prime skin substitute and application.