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

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance; lumbar or sacral, single facet joint (64635, 64636). 
 You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with 
imaging guidance; lumbar or sacral, single facet joint. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary because the records show that the enrollee 
has already had more than 2 radiofrequency sessions in the lumbar/sacral region in the prior 12 months. 
 
The Plan follows Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) 
radiofrequency sessions will be reimbursed per rolling 12 months. 
 
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, 
paravertebral facet joint nerve(s), with imaging guidance; lumbar or sacral, single facet joint. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found this request exceeds the utilization 
limit of 2 sessions per 12-month period. 
 
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, paravertebral facet joint nerve(s), with imaging 
guidance; lumbar or sacral, single facet joint have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; 
lumbar or sacral, single facet joint (64635, 64636).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation. 
 
You asked the Plan to pre-approve the nerve destruction. You say that genicular nerve ablation is the standard 
of care following a successful genicular nerve block. The Plan denied your request. The Plan says the request 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 nerve destruction. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee pain. 
 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 nerve destruction have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve ablation.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes procedure codes G0453, 
95955, 95864, 95939, and 95938. We decided that the Plan does not have to pay for the services described by 
procedure code A4557.  
 
You asked the Plan to pay for procedure codes A4557, G0453, 95955, 95864, 95939, and 95938 billed for date 
of service April 6, 2023. You say that  medical records were submitted. The Plan says that the service is 
bundled into payment for other services. 
 
We decided that the Plan has to pay for the services described by procedure codes procedure codes 
G0453, 95955, 95864, 95939, and 95938.  
 
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 Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure codes procedure codes G0453, 95955, 
95864, 95939, and 95938 billed for date of service April 6, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure code A4557. 
 
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 A4557 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4557 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the services 
described by procedure code A4557 billed for date of service April 6, 2023. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the oxygen concentrator rental, humidifier, and 
CPAP device provided from October 12, 2022, to July 27, 2023. 
 
You asked the Plan to waive the coinsurance for the oxygen concentrator rental, humidifier, and CPAP device. 
You say that you should not owe anything because you never had to pay before. The Plan denied your request. 
The Plan says that the 20% coinsurance has been applied correctly per the Plan's Evidence of Coverage. 
 
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 plan did not send us the Explanation of Benefits (EOB) for the 
DOS at issue. Without the EOBs we can determine if the correct coinsurance was assessed appropriately. 
Therefore, we decided that the Plan has to waive the coinsurance for the oxygen concentrator rental, 
humidifier, and CPAP device provided from October 12, 2022, to July 27, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this is medically necessary for the 
enrollee. You also say that the enrollee's left side is not functional. The Plan denied your request. The Plan says 
the notes do not show a medical need to control the power options through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates that enrollee has left sided weakness. The documentation also indicates that the enrollee has sufficient strength and function in right upper extremity to 
manage standard power drives. Therefore, the reviewer found that the requested upgraded electronics are not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
June 27, 2023, and billed with codes 87798, 87481, 87150, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on June 27, 2023, and billed with codes 87798, 87481, 87150, and 87801.
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 July 28, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. 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 July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services billed with procedure code 95942, 
provided on June 16, 2023, to June 28, 2023, by an out-of-network (OON) provider.  
 
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 the services were provided by an out of network 
provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for practitioner services billed with procedure code 
95942, provided on June 16, 2023, to June 28, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (0241U) provided on January 14, 2023. 
 
You asked the Plan to pay for the services. 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. 
 
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 use of code 0241U is 
not supported by the records provided. Our reviewer found that the documentation does not support the use of 
code 0241U, as the lab order states that code 87631 was used. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for the services (0241U) provided on January 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 30117 and 31231 rendered on May 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 the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 30117: 
 
Excision or destruction (eg, laser), intranasal lesion; internal approach 
 CPT 31231: 
 
Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 30117, the 
provided records document that a NeuroMark radiofrequency stylus was used to treat the interior of the nasal 
cavity for chronic vasomotor rhinitis with chronic congestion. Records do not document the excision or 
destruction (eg, laser) of a specific intranasal lesion. In terms of CPT 31231, the records not document a full 
nasal endoscopy was performed with inspection of the interior of the nasal cavity, the middle and superior 
meatus, the turbinates and the spheno-ethmoid recess as is required for use of CPT code 31231. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 30117 and 31231 rendered on May 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 5, 2023. 
 
You asked the Plan to pay for the lab services. You say that the coding is approved by Medicare. The Plan 
denied your request. The Plan says an incorrect place of service was billed. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on May 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc and Supartz FX is required before alternatives can be 
considered. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 12, 2022, to 
October 13, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that G93.41 
is supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says G93.41 is not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
In this case, you billed the inpatient services provided with secondary diagnosis code G93.41, defined as 
metabolic encephalopathy. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that secondary diagnosis G93.41 is not 
supported in the documentation. Our physician reviewer found the enrollee presented to the hospital with 
hypoglycemia. Glasgow Coma Scale (GCS) score was noted as 15 with the enrollee alert and oriented. It was 
reported that they had flight of ideas and difficulty staying on topic, however, it was noted that this was their 
baseline related to bipolar disorder. It is documented this behavior also occurred when they did not have 
hypoglycemia anymore, supporting the behavior being related to the enrollee's baseline and not metabolic 
encephalopathy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 12, 2022, to October 13, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing provided May 3, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says the PCR testing is 
considered 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 looked at the file and Medicare rules. The standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the Urine PCR panel testing provided May 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) injection (27096). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee is to the point they are not able to 
perform normal physical activities including cooking, standing for a long time, and walking. You also say that 
therapy did not help the enrollee at all. The Plan denied your request. The Plan says this is not medically 
necessary.  
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections (SIJI) will be considered 
medically reasonable and necessary when there are at least three positive findings with provocative maneuvers. 
 
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 injection. Our reviewer says that the 
requested SIJ injection is not medically necessary. Our physician reviewer found there is no documentation on 
physical examination of three (3) or more positive tests results. The clinical value and effectiveness of an SIJ 
injection in the absence of tenderness and negative provocative testing results have not been demonstrated in 
the peer-reviewed literature. The reviewer found that the enrollee does not meet the coverage criteria for an SIJ 
injection.  Therefore, the requested SIJ injection 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint (SIJ) injection (27096).