Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic repetitive transcranial magnetic stimulation 
(TMS) treatment; initial and subsequent, including cortical mapping, motor threshold determination, delivery 
and management (90867, 90868). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that left prefrontal transcranial magnetic stimulation 
(TMS) of the brain is considered medically necessary for use in an adult who meets all four of the indicated 
criteria. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that you are requesting coverage on behalf of the enrollee for Transcranial Magnetic 
Stimulation (TMS) treatment for Major Depressive Disorder, Recurrent, and Chronic. Based upon the review 
of the records provided this enrollee does not meet the clinical criteria for the use of Transcranial Magnetic 
Stimulation (TMS) therapy according to the Local Coverage Determination that the enrollee is currently 
undergoing psychotherapy utilizing a family systems approach. There is no clear evidence of the enrollee 
undergoing psychotherapy considered to be appropriate for the treatment of his depressive disorder. The 
enrollee does not meet the criteria for Transcranial Magnetic Stimulation (TMS) and your request is therefore 
not considered reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial and 
subsequent, including cortical mapping, motor threshold determination, delivery and management (90867, 
90868).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 19, 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 claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 the laboratory services rendered on 
January 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept device. 
 
You asked the Plan to pre-approve an Intracept device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous 
basivertebral nerve ablation at L3, L4, L5, and S1 levels, in this case, is not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Intracept device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 21, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service February 22, 
2023.  
 You asked the Plan to pay for procedure code 76641. You say that this should be paid for. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a quantity of 200 per 90 days of Freestyle Lite test strips. 
 
You asked the Plan to pre-approve a quantity of 200 per 90 days of Freestyle Lite test strip. You say that it is 
necessary for you to test two times a day when you eat four times a day. This will prevent you from using 
insulin and experiencing fluctuation in your glucose. The Plan denied your request. The Plan says that the 
request exceeds the amount allowed. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a quantity of 200 per 90 days of 
Freestyle Lite test strip. Our reviewer says that the item/service meets criteria. Our physician reviewer found it 
seems as if you are trying to control blood sugar better with this - perhaps to adjust your diet. The providers 
office notes do indicate in the medicine list to check blood three times per day so two times a day is reasonable. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of quantity of 200 per 90 days of Freestyle Lite test strip have been met. 
Therefore, we decided that the Plan has to pre-approve a quantity of 200 per 90 days of Freestyle Lite test 
strips.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
from August 18, 2022, to September 9, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that this is a medical necessity 
appeal based on medical literature and the efficacy of the treatment rendered. The Plan denied your request. 
The Plan says the requested water circulating heating pad with pump is non-covered because it is considered 
not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0217 is provided it will be denied as not 
reasonable and necessary. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided from August 18, 2022, to 
September 9, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy with physician supervision 
(G0277, 99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy with physician supervision. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. 
 
   
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 hyperbaric oxygen therapy with 
physician supervision. Our reviewer says that the enrollee does not meet coverage criteria for the requested 
service. Our physician reviewer found the record sent by the provider indicates that the enrollee had ankle 
surgery on May 9, 2023, and the surgical wound is not healing well. The wound is described darker in color. 
There has not been any identifiable evaluation of the vascular supply in the leg, other than a statement from the 
provider that there is "no evidence of peripheral artery disease." However, there is no imaging or other 
objective measurement of the peripheral vascular supply in the leg. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy with physician supervision have not been met. 
Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy with physician 
supervision (G0277, 99183).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 and 99602 billed for date of service 
June 23, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that per benefit verification, all 
codes are covered 100% and no authorization is needed. 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 codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure code 99601 and 99602 is not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99601 and 99602 billed for 
date of service June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 09, 2023. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on February 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on December 30, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the CT scan 
should be paid. 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 $300 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $300 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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. The total you owe is $226.63, which is less than the standard $300 copayment 
for a CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on December 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates for service February 8, 
2022, to March 7, 2022. You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the NOA was 
not received timely.  
 
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 February 8, 2022. The NOA was not received by the Plan until July 27, 
2022. 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 care billed for 
dates for service February 8, 2022, to March 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertiflex procedure (22869). 
 
You asked the Plan to pre-approve the vertiflex procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is considered experimental. 
 
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 procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the service is considered experimental. 
 
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 procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the vertiflex procedure (22869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99203-25, 10060-59, 17004-59, and 17110-
59 provided on August 25, 2022. 
 
You asked the Plan to pay for procedure codes 99203-25, 10060-59, 17004-59, and 17110-59. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
medical 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 code 99203 is Office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and low 
level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on 
the date of the encounter. The definition of code 10060 is Incision and drainage of abscess (eg, carbuncle, 
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single. 
The definition of code 17004 is Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 
surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions. The definition of code 
17110 is Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of 
benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions. 
 
Medicare rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the 
intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We find that CPT codes 99203-25, 10060-59, 17004-59, and 17110-59 are not supported in the medical record. 
Specifically, the one-page record provided is not completely legible. It is unclear if these codes were 
sufficiently described based on Medicare's definition of these codes. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99203-25, 10060-59, 17004-59, and 17110-59 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99203-25, 10060-59, 17004-
59, and 17110-59 provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens, the tint, the anti-reflective coating, the 
deluxe frames, and the deluxe lens feature provided on December 8, 2022. 
 
You asked the Plan to pay for the vision items. You say that the benefits were not applied correctly. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when up to a $175 allowance for vision items and services. 
 
We looked at the file and the Plan's rules. Specifically, the Plan applied the $175 allowance to the eyewear. 
Based on this information, we decided that the Plan's rules for coverage of the vision items have not been met. 
Therefore, we decided that the Plan does not have to pay for the progressive lens, the tint, the anti-reflective 
coating, the deluxe frames, and the deluxe lens feature provided on December 8, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for revision of total knee arthroplasty, with or without allograft; 1 
component rendered on March 16, 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 procedure code 27486 is not supported by the medical records submitted. 
 
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 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 were 
not supported by the medical records. Our reviewer found that the enrollee was being treated for other 
mechanical complication of internal left knee prosthesis. The enrollee underwent a left knee tibial component 
revision and quadriceps mechanism realignment on February 10, 2022. The procedure details cite the femoral 
component was well-fixed. The tibial component was removed with osteotome. This supports that one 
component of the left total knee was revised. 
 
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 
revision of total knee arthroplasty, with or without allograft; 1 component rendered on March 16, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require IRF services to address functional 
deficits and would benefit from multiple intense therapies. The Plan denied your request. The Plan says the 
request 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 IRF admission and services.