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

 
We decided that the Plan does not have to pay for procedure codes 45385, G0500 and 99153 billed for date of 
service August 18, 2022. 
 You asked the Plan to pay for procedure codes 45385, G0500 and 99153. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the provided 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. The rules also say that the OPPS recognizes that 
CPT code 99153 is a PE only code and that PE are not payable to the physician for services provided in the 
facility setting.  
 
In this case, the CPT Code Manual definition of code 45385 is: Colonoscopy, flexible; with removal of 
tumor(s), polyp(s), or other lesion(s) by snare technique. 
 
The definition of code G0500 is: Moderate sedation services provided by the same physician or other qualified 
health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the 
presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness 
and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time 
may be reported with 99153, as appropriate) 
 
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 procedure codes 45385 and G0500. Our reviewer says that 
procedure codes 45385 and G0500 do not meet criteria for payment. Our reviewer found that the procedure 
report for code 45385 describes a Mucosa biopsy with cold forcep. In this case, there is a more specific 
procedure code that should be reported. The procedure report does not include sufficient documentation to 
verify procedure code 45385. The procedure report for code G0500 does not include sufficient documentation 
to verify initial 15 minutes of intra-service time, as time is not documented. The procedure report states, 
"Please see procedure record form 692 for moderate sedation duration"; however, this report was not found in 
the medical record. 
 
We looked at this coder's review, the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 45385 and G0500 have not been met. Additionally, we find 
that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician 
for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have 
to pay for procedure codes 45385, G0500 and 99153 billed for date of service August 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the cervical spine to be provided by an 
OON provider.  
 
You asked the Plan to pre-approve the CT scan. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says this service can be provided by an in-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 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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a CT scan of 
the cervical spine to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three chiropractic visits. 
 
You asked the Plan to pre-approve the chiropractic visits. You say that your physician agrees that you should 
continue chiropractic services so that you can get better and not get worse. You say that the only thing taking 
its time is your pinky finger because of the nerve damage. The Plan denied your request. The Plan says  the 
request is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
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 the chiropractic visits. Our reviewer 
says that the chiropractic visits are not medically necessary. Our physician reviewer found that you have 
cervical subluxation and radiculopathy. However, the records of the visits do no support progressive 
improvement of symptoms, and that further improvement is reasonably expected but rather that the requested 
service is maintenance therapy. Therefore, the elements of the coverage criteria are not satisfied, and the 
requested service is not 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 chiropractic visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve three chiropractic visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis (L3670) provided May 2, 2023. 
 
You asked the Plan to pay for the orthosis. You say that you are attaching additional documentation in order to 
process your claim. The Plan denied your request. The Plan says please resubmit the claim with the appropriate 
modifier for procedure. 
 
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 L3670 is shoulder orthosis (SO), acromio/clavicular 
(canvas and webbing type), prefabricated, off-the-shelf. 
 
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 orthosis. Our reviewer says that the documentation 
submitted was reviewed and does not meet criteria. Our reviewer found the provider reported Healthcare Common Procedure Coding System (HCPCS) code L3670. The billed procedure does not include a modifier 
identifying purchase or rental. Modifiers are used to provide more information about the item, and when 
reported in correct or missing, claim would be denied. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the shoulder orthosis (L3670) provided May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says this procedure is considered experimental and 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 the block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered experimental therapy. It is the subject of ongoing clinical trials. Therefore, the 
request is deemed not medically reasonable and 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 block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a genicular nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that without getting the therapy that you need your health 
and well being will decline rapidly to the point that you will not be able to meet your baseline levels to be 
safely transferred from the hospital, skilled nursing facility or home health care. 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 you are ready for hospital discharge but you require contact guard assistance 
with transfers and to ambulate 3 feet with a rolling walker. You do not need a physical and medicine 
rehabilitation doctor twice weekly, nor do you need an intensive team for her 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee does not have complicated 
wounds or multiple complicated medications which cannot be given in the current hospital and can remain in 
the current acute care location until such time no further acute level care is needed. The Plan denied your 
request. The Plan says admission is medically necessary for the enrollee. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Given there are offered alternatives, LTACH is not 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is weak and prior to hospitalization was 
independent and  not strong enough to go home.The enrollee is a high fall risk  needing occupational and 
physical therapy to get back to independence. The Plan denied your request. The Plan says the enrollee's 
condition does not meet all the requirements for inpatient rehabilitation admission. The Plan says services may 
be provided at a lower level of care.  
 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 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 medical 
records support a need for physical 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. It 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (77523). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested therapy is 
medically necessary. The Plan denied your request. The Plan says the requested therapy 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 proton beam radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the use of proton therapy is an accepted radiation technology, which has 
proven efficacy and tolerability. There is no clear evidence that proton beam therapy for prostate cancer offers 
any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish 
a possible advantage of this expensive therapy. To date, there is no compelling data to suggest that proton 
therapy is superior to or more beneficial than intensity-modulated radiation therapy (IMRT)/image-guided 
radiation therapy (IGRT). The generally accepted standard of care for prostate cancer is to only offer proton 
beam therapy on clinical trials, and to not routinely offer it to patients. While National Comprehensive Cancer 
Network (NCCN) guideline consider proton therapy a reasonable alternative they do not describe it as being 
necessary in lieu of non-proton-based treatment and are quite explicit in that there is no evidence of its 
superiority. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy (77523).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 7, 2023, billed 
with procedure codes 99214-25, 96365-59, 96366-59 (x2), and 96521. 
 
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 level of care is not supported, and the OIVIT 
services are non-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. The rules also say that services comprising of an 
OIVIT regimen are nationally non-covered under Medicare when furnished pursuant to an OIVIT regimen. 
 
In this case, the CPT Code Manual definition of code 99214-25 is office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the provider documentation does not 
include an appropriate history. The enrollee presented for a planned procedure and the medical decision 
making was not of moderate complexity. 
 
We looked at this coder's review, the file, and Medicare rules. The OIVIT services appropriately denied as 
these services are non-covered. Based on this information, we decided that Medicare rules for coverage of the 
practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on September 7, 2023, billed with procedure codes 99214-25, 96365-59, 96366-
59 (x2), and 96521.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5225), and a partial 
mandibular denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve these 
dentures. The Plan denied your request. The Plan says your benefit for the requested item or service 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service on June 11, 2020, and August 20, 2020. Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture 
(D5225), and a partial mandibular denture (D5226).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cupping therapy for treatment of back pain. 
 
You asked the Plan to pre-approve cupping therapy for treatment of back pain. You say that on your last 
approved treatment you received cupping. You say that you are in severe pain and this procedure has been 
approved for years for treatment and you have not been helped by any other treatment The Plan denied your 
request. The Plan says there is no evidence in the published literature that cupping significantly improves back 
pain. There are not enough studies on cupping to show it is safe and effective. Therefore, it not considered 
standard of care. 
 
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 cupping therapy for treatment of back 
pain. Our reviewer says that the requested cupping therapy is not considered medically reasonable and necessary. Our physician reviewer found that cupping does not appear to be efficacious in the treatment of low 
back pain. Therefore, the request is deemed not medically reasonable and 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 cupping therapy for treatment of back pain have not been met. Therefore, we 
decided that the Plan does not have to pre-approve cupping therapy for treatment of back pain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and 
accessories (E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0040). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are unsure how the 
Plan's denial can state that Medicare would not approve the requested items when the approval from Medicare 
was attached in the authorization. The Plan denied your request. The Plan says the enrollee does not have a 
medical need for multiple power options included with a group 3 power wheelchair. The Plan also says the 
electronic connection, expandable controller harness, and expandable controller cannot be covered as it is not 
medically necessary to control the three requested power options through the joystick (drive interface). 
 
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 a power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee's current wheelchair does not have power seat options. The 
enrollee has intact skin and is dependent for meal preparation. She is able to operate her current wheelchair 
with a standard joystick. Per L33789, the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and accessories (E0955, 
E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2607, E2620, K0040).