Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an Avertix Guardian device (0525T). 
 
You asked the Plan to pre-approve an Avertix Guardian device. You say that an Avertix Guardian device is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the Avertix Guardian device is 
experimental/investigational. 
 
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 an Avertix Guardian device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of the requested cardiac ischemia monitor (Avertix 
Guardian) in patient management.  
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 Avertix Guardian device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an Avertix Guardian device (0525T).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (74177) provided on February 17, 2023. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 74177 is not supported in the medical record. Specifically, diagnosis codes K92.2 
(Gastrointestinal hemorrhage, unspecified) and K57.30 (Diverticulosis of large intestine without perforation or 
abscess without bleeding) have an Exclude note and cannot be billed together. Based on this information, we 
decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided 
that the Plan does not have to pay for radiology services (74177) provided on February 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) billed for date of service 
February 5, 2023. 
 
You asked the Plan to pay for initial hospital care. You say that this service was reported appropriately and 
should be paid. The Plan denied your request. The Plan says this code is not supported as 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 code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 We find that CPT code 99223 is not supported in the medical record. Specifically, the records provided show 
that this same provider also billed code 99223 for initial hospital care for date of service February 4, 2023. This 
means that the visit at issue would be coded with a subsequent visit code. Based on this information, we 
decided that Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for initial hospital care (99223) billed for date of service February 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97016, J3411, J3415, and G0283 billed for 
November 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 97016 is application of a modality to 1 or more areas; 
vasopneumatic devices. The definition of code J3411 is injection, thiamine hcl, 100 mg. The definition of code 
J3415 is injection, pyridoxine hcl, 100 mg. 
 
We find that CPT codes 97016, J3411, and J3415 are not supported in the medical record. Specifically, the 
records do not indicate that application of modality to one or more areas with vasopneumatic devices was 
performed for the billed date of service to support code 97016. The file shows that a nutria-pharmaceutical 
blend was administered and there is a more appropriate code for these services other than J3411 and J3415. 
 
The rules say that the use of Physical Medicine and Rehabilitation CPT/HCPCS Codes (97032, 97139, G0282, 
G0283) for nerve blocks and electrostimulation for peripheral neuropathy is inappropriate. The file shows that 
code G0283 was billed in this instance and is therefore not allowed by Medicare. 
 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 97016, J3411, J3415, and G0283 
billed for November 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on January 
6, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have billed the services 
at issue correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
  The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to ESRD provided on January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be reprocessed accordingly for prompt 
payment. 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, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart cardiac contractility modulation 
system (CCM). 
 
You asked the Plan to pre-approve the Optimizer Smart device. You say that the enrollee has failed 
conservative treatment. You also say that this is medically necessary for the enrollee. The Plan denied your 
request. The Plan says this device is considered experimental and therefore is not a covered benefit. 
 
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 Optimizer Smart device. Our 
reviewer says that the requested Optimizer Smart device is not considered medically reasonable and necessary 
in this case. Our physician reviewer found CCM remains the subject of multiple studies examining long-term 
efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. Therefore, 
the reviewer found that the requested Optimizer Smart device is not medically reasonable or necessary at this 
time. 
 
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 Optimizer Smart device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Optimizer Smart cardiac contractility modulation system (CCM).
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 is a candidate for admission to an IRF 
and with therapy, the enrollee will be able to return home instead of going to a SNF. The Plan denied your 
request. The Plan says the enrollee does not meet all the requirements for an IRF admission. 
 
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 enrollee's 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 20, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services (A0130, A0425) provided on 
February 8, 2023. 
 
You asked the Plan to pay for transportation services. You say that this claim must be reprocessed. The Plan 
denied your request. The Plan says this claim was submitted with an inappropriate primary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that manifestation codes have a "code first" note and should be sequenced after an appropriate 
etiology code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of transportation services have not been met. Specifically, the only/primary diagnosis reported on this claim is Z99.3 (dependence on wheelchair). Diagnosis code Z99.3 has a "code first" note, instructing providers 
to report the cause of dependence before code Z99.3. This means that it is not appropriate to use this diagnosis 
code alone or as a primary diagnosis. Therefore, we decided that the Plan does not have to pay for 
transportation services (A0130, A0425) provided on February 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve flexible protective outer surface covering system 
(L5962). 
 
You asked the Plan to pre-approve flexible protective outer surface covering system. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific are 
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 flexible protective outer surface 
covering system. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found provided medical records do not document that the enrollee will be exposed to such an unusually harsh 
and difficult environment that the standard prosthetic cover would be inadequate for his needs. Provided records in this case document the enrollee's occupation as "disabled." Although records from the device vendor 
argue medical necessity of the requested device, records from the enrollee's actual treating provider do not 
clarify why the standard prosthetic cover would be inadequate for the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of flexible protective outer surface covering system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve flexible protective outer surface covering system 
(L5962).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication-assisted treatment billed with code G2067 is 
February 23, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that only an entity enrolled with Medicare as an opioid 
treatment program (OTP) can bill codes G2067-G2075, G2076-G2080, G2215, G2216, and G1028. 
 
We looked at the file and Medicare rules. The file shows that code G2067 was not billed by a provider enrolled 
as an OTP. It is noted that the provider is certified through Substance Abuse and Mental Health Services 
Administration (SAMSA), but there is no record that the provider is Medicare-certified as an OTP. Therefore, we decided that the Plan does not have to pay for the medication-assisted treatment billed with code G2067 is 
February 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 18, 2022, billed with 
codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81351, 81406, 
81437, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 18, 2022, billed with codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 
81321, 81334, 81351, 81406, 81437, and 81479.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to go to an acute inpatient rehabilitation 
facility. The Plan denied your request. The Plan says an IRF admission 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient services provided from July 8, 2020, to July 14, 2020, at the 
original rate billed. 
 
You asked the Plan to pay for inpatient services. You say that these services were medically necessary and 
were reported appropriately. The Plan denied your request. The Plan says that these services are not supported 
as billed. Although additional medical records were requested, none were provided. 
 
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 file provided notes that some medical records were submitted, 
and it is due to missing documentation in these records that the submitted rate code billed was changed. The 
Plan states that additional records were requested multiple times. However, the Plan did not include the original 
records or any evidence that additional documentation was requested in the case file. Without this information, 
we cannot verify the Plan's denial in this case. The Plan has failed to substantiate their decision. Therefore, we 
decided that the Plan has to pay for inpatient services provided from July 8, 2020, to July 14, 2020, at the 
original rate billed.  
 
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.