Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to provide hip surgery revision and repair. 
 
You asked the Plan to provide hip surgery revision and repair. You say that there are no in-network revision 
specialists capable of performing this procedure and delay may result in permanent damage. The Plan denied 
your request. The Plan says that that in-network providers are available for this procedure. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 provide hip surgery revision and repair. Our 
reviewer says that the requested service is recommended. Our physician reviewer found that the record 
indicates that the enrollee requires urgent revision of hip surgery. The record provided indicates that the Plan 
has in-network providers, but no appointment is available for at least one month, pending record review to 
determine if they can provide the care. The Plan has not documented that they have in-network providers who 
meet the Standards of Care required for treatment of the enrollee's condition. The elements of the coverage 
criteria required for out-of-network coverage are satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hip surgery revision and repair have been met. Therefore, we decided that the 
Plan has to provide hip surgery revision and repair.  
 
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: Favorable

 
We decided that the Plan has to pre-approve transplant services from an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve transplant services from an OON provider. You say that the enrollee has an 
extensive psychiatric history that their team has closely monitored over the last 3 years. You say that you have 
provided extensive care to the enrollee to ensure a stable equilibrium, and that the enrollee is now ready for 
kidney transplantation. You say that, due to the emotional changes of receiving a new kidney coupled with the 
immunosuppression medications post-transplant, the enrollee is at high risk for recurrence of her psychiatric 
illnesses. You say that it is essential for the perioperative and post operative transplant care to occur at their 
center to ensure safe continuity of care and to prevent harm to her life. You say that you are concerned that 
transplant care at a facility unfamiliar with the complex nuances of the enrollee's history will threaten her 
longevity.  The Plan denied your request. The Plan says that medically necessary care is available in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 transplant services from an OON provider. Our reviewer says that the criteria for coverage OON have been met. Our physician reviewer found 
the enrollee has an extensive Psychiatric history. The enrollee has the Psychiatric support system in place with 
the OON provider that is not available at the in-network center. While Psychiatric care would be available at 
the in-network center, it would not provide the same level of care due to the specific nature of the needs of this 
patient. Psychiatric specialists without the long-term relationship and familiarity of this individual's case would 
be not as well equipped to handle the challenges that will go along with transplant and will not be able to judge 
the appropriateness of the transplant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transplant services from an OON provider have been met. Therefore, we 
decided that the Plan has to pre-approve transplant services from an out-of-network (OON) provider.  
 
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 to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve OON IRF care. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says in-network providers are available. 
 
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 
IRF admission and services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 8, 2023, billed with 
codes G0453, 95937-26, 95938-26, and 95860-26. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that M54.2 has an Excludes1 note in relation to M50.021. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does 
not have to pay for practitioner services provided on March 8, 2023, billed with codes G0453, 95937-26, 
95938-26, and 95860-26.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is noted to have memory 
problems. The most recent neurology evaluation was said to have been most consistent with early onset AD. 
The magnetic resonance imaging showed features suggestive of AD. There was no support noted in the second 
evaluation for a concurrent diagnosis of FTD. 
 
   
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system (A4305) and supplies 
(A4223). 
 
You asked the Plan to pay for the disposable drug delivery system and supplies. You say that the items were 
medically necessary. The Plan denied your request. The Plan says these are not covered items. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment. Drugs and supplies used with disposable drug delivery 
systems are also non-covered items. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the disposable drug delivery system and supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for the disposable drug delivery system (A4305) and supplies (A4223).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Byooviz. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vabysmo. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drug, Byooviz. The reviewer also found that there is 
no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services coded as 74240, 74230, 72040, 70100, 
and 70310 performed on date of service March 13, 2023. 
 
You asked the Plan to pay for the radiology services. You say that radiology services should be paid as billed 
because each code represents a distinctly different procedure that was medically necessary. The Plan denied 
your request. The Plan says the radiology services are denied because they were billed with an inappropriate 
POS. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology services performed in the mobile 
setting are not eligible for reimbursement if they are listed in the Exclusions from Coverage as Portable X-Ray 
Services section of the Medicare Benefit Policy Manual. Medicare rules also state that claims must be billed 
with the appropriate POS.  
 
We looked at the file and Medicare rules. Documentation provided shows codes 74240 and 72430 were 
performed in a mobile unit setting with the use of fluoroscopy. Therefore, they are not covered and are 
excluded under the portable x-ray provision. Codes 72040, 70100, and 70310 were billed with POS 11, 
indicating an office setting. However, documentation shows the radiology services were performed in a mobile 
setting at a Skilled Nursing Facility. There is no evidence the services were provided in an office setting. 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 the radiology services coded as 74240, 74230, 
72040, 70100, and 70310 performed on date of service March 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93970 billed for date of service October 21, 
2022.  
 
You asked the Plan to pay for procedure code 93970. You say that there are no code edits for the code pair. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 93970 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were correctly coded. The 
file shows that a bilateral carotid duplex and bilateral lower extremity venous duplex were billed with code 
93970. If a complete or limited bilateral study is done on both the upper and the lower extremities, the 
corresponding code can be reported once for each study performed (i.e., once for the upper extremities and 
once for the lower extremities). Providers should append modifier 76, repeat service by the same provider, or 
modifier 77, repeat service by another provider, to the second code to indicate that two separate, distinct studies 
were performed. There should be a separate written report/interpretation for each study performed. Based on 
this information, we decided that Medicare rules for coverage of procedure code 93970 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 93970 billed for date of service 
October 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve destruction by neurolytic agent, 
genicular nerve branches including imaging guidance. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found this is 
considered experimental therapy. It is the subject of ongoing clinical trials.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, genicular nerve branches including imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 billed for date of service August 22, 
2022. 
 
You asked the Plan to pay for the billed services. You say that routine drug testing is necessary to monitor 
prescriptions. The Plan denied your request. The Plan says the billed code is not supported. 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 G0480 is definitive drug testing of 1-7 drug classes. We 
find that CPT code G0480 is not supported in the medical record. The records provided do not show that the 
testing of 1-7 drug classes was ordered based on the enrollees clinical assessment or other clinician 
documented change in affect or behavioral pattern. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code G0480 billed for date of service August 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that due to the enrollee's medical condition 
LTACH is recommended. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee continues to receive acute care services, and these have not been 
denied.  The medical record does not indicate that the enrollee requires services that she is not currently 
receiving but that would be available at the LTACH facility.  The elements of the coverage rules are not 
satisfied.  The requested service cannot be recommended. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing and validity testing (80307, 83789) billed for 
date(s) of service June 8, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Additionally, the documentation submitted does not contain a valid physician order or lab 
requisition for the specific drug testing provided in this case. Therefore, we decided that the Plan does not have 
to pay for the drug testing and validity testing (80307, 83789) billed for date(s) of service June 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the toothbrush instruction (D1330), a filling (D2392) for 
tooth #20, a pontic (D6245) for tooth #8 and #9, a retainer crown (D6740) for tooth #6 and #11, and 
provisional retainer crown (D6793) for tooth #6, #7, #8, #9, #10, and #11. 
 
You asked the Plan to pre-approve the dental services. You say that you need the dental work done so they can 
eat solid food. The Plan denied your request. The Plan says the denial of authorization for the bridge is correct 
because there are missing many teeth for the bridge. The toothbrush instruction is not covered by the Plan. 
Also, your benefit for the filling has already been exhausted. 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the bridge coverage criteria was not met. Our physician reviewer found that a fixed bridge may be 
considered for coverage to replace a single missing maxillary anterior tooth when there are no other teeth 
missing in the arch. In this case, teeth #2, #3, #4, #5, #8, #9, and #15 are missing in the maxillary arch. Other 
means of replacement should be considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics, retainer crowns, and provisional retainer crowns have not been met. 
The record shows your benefit for the filling was exhausted on the date of service of August 4, 2023. The 
toothbrush instruction is not covered under the Plans dental benefit. Therefore, we decided that the Plan does 
not have to pre-approve the toothbrush instruction (D1330), a filling (D2392) for tooth #20, a pontic (D6245) 
for tooth #8 and #9, a retainer crown (D6740) for tooth #6 and #11, and provisional retainer crown (D6793) for 
tooth #6, #7, #8, #9, #10, and #11.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet evidence-based criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease. 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).