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

 
We decided that the Plan does not have to pre-approve the deep brain stimulation (DBS) procedure (61886). 
 
You asked the Plan to pre-approve the DBS procedure. You say that the inpatient surgery is already approved. 
You also say that approval is required for outpatient portion of surgery as well. The Plan denied your request. 
The Plan says this procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the DBS procedure. Our reviewer says 
that the requested DBS procedure is not medically necessary. Our physician reviewer found the provided 
documentation does support that the enrollee has an essential tremor. The guidelines indicate that this 
procedure is only covered for essential tremor under certain condition. However, the reviewer also found that 
the provided documentation is not sufficient to determine that the coverage criteria have been met. Therefore, 
the reviewer found that  
 
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 DBS procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the deep brain stimulation (DBS) procedure (61886).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (0242U) provided on December 2, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported for the date of service in question. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 0242U is not supported in the medical record. Specifically, the 
documentation does not show that the specimen was collected on December 2, 2022. 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 pay for the lab services (0242U) provided on December 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Prolia. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the enrollee has a diagnosis of 
osteopenia. The review has determined that the documentation does not support that Prolia is medically 
reasonable or necessary. The documentation does not support that Prolia is safe and effective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 3, 2022, to 
August 1, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have billed the services at 
issue correctly. 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 3, 2022, to August 
1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee lives alone and prefers to stay in his 
home. You say to achieve this, the enrollee needs intensive care and therapy at an IRF. The Plan denied your 
request. The Plan says admission to an IRF is not medically necessary.  
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 the 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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy (36473). 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that the enrollee reports that their 
veins are completely blocked. You say that this causes immense pain. You also say that this procedure is the only thing that would help, per your provider. The Plan denied your request. The Plan says the enrollee has not 
trialed at least three months of conservative therapy. 
 
The Plan follows Medicare rules. Medicare rules say that endovenous ablation therapy is indicated after a three 
month trial of conservative therapy. 
 
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 endovenous ablation therapy. Our 
reviewer says that the requested endovenous ablation therapy is not medically necessary. Our physician 
reviewer found the provided documentation does not support that the enrollee is having activity or mobility 
limiting symptoms attributable to the varicose vein. The reviewer also found that there is no evidence of any 
efforts at conservative treatment. Therefore, the reviewer found that the requested endovenous ablation therapy 
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 endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy (36473).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are having difficulty walking and doing basic 
tasks and are fearful of a fall. You also say a fall could be fatal. The Plan denied your request. The Plan says 
based on the medical records received, your condition does not meet the Medicare guidelines 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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 you 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service December 8, 
2022. 
 
You asked the Plan to pay for procedure code 99223. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is: Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, code 99223 is an inpatient 
code for the date of service at issue. In this case, the code has been reported with a Place of Service (POS) code 
of 22, indicating an outpatient setting. The POS does not correspond to the code billed. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99223 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99223 billed for date of service 
December 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76642, 77066, and G0279 billed for date of 
service January 17, 2023.  
 You asked the Plan to pay for procedure codes 76642, 77066, and G0279. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 76642, 77066, and G0279 is 1. The MAI value for this code is 2. You 
billed 2 units of each of these codes, exceeding the MUE. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 76642, 77066, and G0279 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 76642, 77066, and G0279 billed for date of service January 
17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device.  
 
You asked the Plan to pre-approve the Vertiflex Superion device. You say that Medicare has been known to 
cover the interspinous decompression spacer procedure. The Plan denied your request. The Plan says the 
requested Vertiflex Superion device is unproven and 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 Vertiflex Superion device. Our 
reviewer says that the requested Vertiflex Superion device is not considered medically reasonable and 
necessary. Our physician reviewer found that the Vertiflex Superion device is experimental. More research is 
needed. 
 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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99222 billed for date of service September 1, 2022. 
 
You asked the Plan to pay for code 99222. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says code 99222 is not supported by the medical record. The medical 
records do not support a comprehensive history. 
 
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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) 
and the patients and/or familys needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patients hospital floor or unit. 
 
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 code 99222. Our reviewer says that code 99222 is not 
supported by the medical record. Our reviewer found the enrollee is a 65year-old woman who presented with 
shortness of breath and was found to be hypoxic. The documentation supports a comprehensive exam, but not a 
comprehensive history or medical decision making of at least moderate complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99222 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99222 billed for date of service September 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service December 3, 
2022, to January 1, 2023. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 4, 2022. The NOA was not received by the Plan until January 18, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for 
date of service December 3, 2022, to January 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 32555-LT billed for date of service February 
13, 2023. 
 
You asked the Plan to pay for procedure code 32555-LT. You say that this service was billed appropriately 
with the correct modifier appended. The Plan denied your request. The Plan says this claim was submitted with 
an inconsistent procedure modifier and diagnosis 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 say that some ICD-10-CM codes 
indicate laterality, specifying whether the condition occurs on the left, right or is bilateral.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 32555-LT have not been met. Specifically, this code was submitted with a left 
modifier, but the diagnosis code reported (C64.1) is for malignant neoplasm of right kidney, except renal 
pelvis. The procedure and the diagnosis are inconsistent regarding which side is affected in this case. 
Therefore, we decided that the Plan does not have to pay for procedure code 32555-LT billed for date of 
service February 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve (Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee's pain is disabling, affects 
their quality of life on a daily basis and has been long-term duration. You say that the enrollee has failed non-
operative treatment. You also say that this is the only solution for the enrollee. The Plan denied your request. 
The Plan says this procedure 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found additional study is needed to validate any benefit of the procedure, and to compare it to other interventions. The lumbar spine magnetic resonance scan for the enrollee in this case shows 
significant degenerative disc disease which may be causing the back pain. The generally accepted standard of 
care for the Intracept procedure would require that imaging shows no other source for the enrollee's back pain 
except for signs consistent with vertebrogenic pathology. Therefore, the reviewer found that the requested 
Intracept 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services: medical 
examination and evaluation and an eye refraction provided on November 14, 2022. 
 
You asked the Plan to waive the copayment for the ophthalmological services: medical examination and 
evaluation and an eye refraction. You say that you did not go to this provider for an eye problem, but for an 
annual exam. The Plan denied your request. The Plan says this cost sharing was charged correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for vision care out-of-network.  
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
You have been asked to pay a $75 copayment for the ophthalmological services: medical examination and 
evaluation out-of-network. This service falls within the vision care benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Medicare does not cover refractive procedures 
even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we 
decided that the Plan does not have to waive the copayment for ophthalmological services: medical 
examination and evaluation and an eye refraction provided on November 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect test (0012M) provided February 8, 
2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial of coverage for 
the Cxbladder Detect test. The Plan denied your request. The Plan says the CX Bladder panel remains 
unproven at this time. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Cxbladder Detect test (0012M) provided February 8, 2023.