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

 
We decided that the Plan does not have to pay for procedure codes 36245 and 76937 rendered on June 27, 
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 denied codes remain 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 the denied codes is: 
 
CPT 36245: 
 
Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family 
 
CPT 76937: 
 
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary 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 the documentation does not 
support that the service indicated by CPT 36245 was rendered. This code applies if there was selective access 
of a branch artery. In this case, a non-selective catheterization of the aorta was performed but the code used 
does not match.  While the work done for CPT 76937 was performed, this add on code can only be applied 
once the proper initial code is provided. The initial code was not supported, so the add-on code is not 
supported.  
 
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 36245 and 76937 rendered on June 27, 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 Intracept procedure. You say that this procedure is safe and efficacious. 
The Plan denied your request. The Plan says the Intracept procedure does not meet established standard of care 
treatment for low back pain nor the Plan medical necessity requirements. 
 
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 that the provided magnetic resonance imaging of the lumbar spine from January 19, 
2023 did not corroborate Modic changes at all of the requested levels. Also, in this case, there were/are 
multiple plausible pathologic sources of significant pain generation. The chronic back pain and intact limited exam were/are all non-specific to any pathologic entities. Overall, documentation was/is lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support 
actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or 
reasonable at this time. 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 L4, L5, and S1 vertebral bodies, 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 11, 2023, to 
January 16, 2023, 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 the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 A41.89, described as other specified sepsis. 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 documentation does not support the billed code. Our physician 
reviewer found that the Sepsis-3 criteria is not met as there was insufficient evidence provided of the patient 
experiencing organ failure directly related to a dysregulated response to infection as required. Therefore, the 
code, A41.89 (sepsis) is not supported for this admission.  
 
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 January 11, 2023, to January 16, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve D9944. You say that you are grinding your teeth at night. The Plan denied 
your request. The Plan says the denied service is not a covered dental benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard (D9944).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on June 28, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be 
considered integral to, and therefore included in the payment for the injection service or other procedure provided. Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on June 
28, 2023.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is receiving the care needed in the current 
hospital. The Plan says when the enrollee is ready to leave the hospital, services may be provided in another 
setting such as a skilled nursing facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453-59 rendered on October 25, 2022. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code G0453-59 (17 Units) remains not 
supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services. Our reviewer says that the 
services at issue in this were not supported by the medical records. Our physician reviewer found that the 
record does not support that G0453-59 is a separately identifiable procedure. The record shows that G0453 is 
included in the electroencephalogram (EEG) neuromonitoring reported with 95955 and should not be reported 
separately.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code G0453-59 rendered on October 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mohs micrographic technique provided on July 11, 2023. 
 
You asked the Plan to pay for mohs micrographic technique. You say that the services should be covered. 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 mohs micrographic 
technique provided on July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power conversion device (E0983), installation of the 
power conversion device (K0108), and accessories to the power conversion device (K0108x7 and E1028). 
 
You asked the Plan to pre-approve the power conversion device, installation, and accessories. The Plan denied 
your request. The Plan says these items were denied because Medicare does not cover these items or services. 
 
The Plan must follow Medicare rules. Medicare rules say that an add-on to convert a manual wheelchair to a 
joystick-controlled power mobility device (E0983) 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 power conversion device, installation, and accessories have not been met. Specifically, because 
the power conversion device (E0983) was denied, the associated installation and accessories cannot be covered. 
Therefore, we decided that the Plan does not have to pre-approve a power conversion device (E0983), 
installation of the power conversion device (K0108), and accessories to the power conversion device (K0108x7 
and E1028).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 24, 2023. 
 
You asked the Plan to pay for the lab services. You say that the testing can have an impact on the choice of 
treatment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. 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 July 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29581 rendered on June 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 prior findings were upheld for CPT 29581. 
 
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 29581 is "Application of multi-layer compression 
system; leg (below knee), including ankle and foot." 
 
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 CPT code 29581 is not supported. 
The record states that an unna boot was applied. There is a more specific code for this procedure. The procedure was not coded to the highest level of specificity. 
 
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 code 29581 rendered on June 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 26, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. 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 the laboratory services 
provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bariatric surgery consultation to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the OON surgery consultation. You say that you feel that this provider is an 
expert and is the only one who can assist you. The Plan denied your request. The Plan says the services 
requested can be provided by any bariatric surgeon in the Plan's network. Since there is no deficiency of the 
network, OON 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 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 provider at issue in this case is not a network provider with the Plan. 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 OON surgery consultation. Our reviewer says that the documentation 
does not support the medical necessity for these services to be provided OON. Our physician reviewer found 
you underwent open duodenal switch in 1994. This is a preservice request for referral to a bariatric surgeon 
outside of your insurance network. You are suffering with malabsorption post-bariatric surgery and want to see 
your original surgeon. However, there is no medical documentation as to why an in-network bariatric surgeon 
cannot provide the services you require.  
 
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 OON surgery consultation have not been met.  
 
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 the OON surgery consultation. Therefore, we decided 
that the Plan does not have to pre-approve bariatric surgery consultation to be provided by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visits provided from February 22, 2023, 
to August 30, 2023. 
 
You asked the Plan to reimburse you for the office visits. You say that it was your understanding that you 
would be reimbursed for the services. You say that you are finding out that the provider is not accepting 
Medicare. You say that you just want to get refunded. You also say that you did get paid for some of the 
services. The Plan denied your request. The Plan says the services were processed correctly based on the 
Evidence of Coverage. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. The record shows that the Plan paid for the date of service on February 
22, 2023, in error, but will not recoup the payment. You have been asked to pay a $22.48 copayment for the 
office visit provided on February 22, 2023. This service falls within the physician services 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. Therefore, we decided that 
the Plan does not have to reimburse you for the office visits provided from February 22, 2023, to August 30, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for external mobile cardiovascular telemetry with 
electrocardiographic recording (ECG) received on July 31, 2023. 
 
You asked the Plan to pay for external mobile cardiovascular telemetry with ECG. You say that this was 
prescribed by your heart doctor and as far as you knew, it was covered by insurance. The Plan denied your 
request. The Plan says the services received are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 93228 and 93229 can only be 
reported once per 30 days. 
 
We note the Local Coverage Article (LCA) used by the Plan to substantiate their denial was LCA A57476. 
This LCA is not valid for the appropriate jurisdiction. Therefore, we are unable to use LCA A57476 to 
substantiate our decision. 
 
We looked at the file and Medicare rules. Review of the file shows that you previously received these services, 
and a claim was processed/paid by the Plan on July 13, 2023. Thirty (30) days had not past since your 
previously received services. Based on this information, we decided that Medicare rules for coverage of 
external mobile cardiovascular telemetry with ECG have not been met. Therefore, we decided that the Plan does not have to pay for external mobile cardiovascular telemetry with electrocardiographic recording (ECG) 
received on July 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) (0037U) provided July 27, 
2023. 
 
You asked the Plan to pay for the genetic testing. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS (Centers for Medicare & Medicaid Services) to 
be reasonable and necessary for the management of the enrollee's advanced cancer. The Plan denied your 
request. The Plan says per Medicare guidelines this 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 pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the reviewed documentation indicates that the enrollee's lung cancer is a new diagnosis, it has 
not previously been treated and is not in advanced stages. The review has determined that the medical records 
provided did not meet the medically necessary requirements listed in the NCD for Medicare coverage. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the FoundationOne CDx (F1CDx) (0037U) provided July 27, 2023.