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

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found one double-blind randomized study has shown that improvement with the Intracept 
procedure was not clinically significant when compared with a sham procedure. Additional studies suggest that 
the Intracept procedure may be more effective for low back pain than conservative treatment. Limitations of the published medical literature include a limited number of studies, industry funding of the studies, and a high risk 
of bias from lack of controls. Additional study is needed to validate any benefit of the procedure, and to 
compare it to other interventions. In addition, provided records document facet arthrosis and other degenerative 
changes on spinal imaging which may be the cause of the patient's back pain. Provided records in this case do 
not document the Intracept procedure meets Medicare criteria for safe, effective, 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient mental health on April 18, 
2023, to May 31, 2023. 
 
You asked the Plan to waive the coinsurance for outpatient mental health. You say that you feel it should be 
considered because you had no idea of the 20% you had to pay. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
 
 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance per Medicare-covered visit for outpatient mental health care. Covered services include Mental 
health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, 
clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health care 
professional as allowed under applicable state laws. The provider billed in the amount of $300 and the allowed 
amount is $192.60 for the service. $192.60 x 20% = $38.52. The provider billed in the amount of $600 and the 
allowed amount is $380.97 for the service. $380.97 x 20% = $76.19.  The provider billed in the amount of $500 
and the allowed amount is $221.41 for the serivice. $221.41 x 20% = $44.28. There were nineteen visits. 19 x 
$44.28 = $841.32. For all services it's $841.32 + $38.52 + $76.19 = $956.03. Therefore, results in the total cost 
sharing amount of $956.03.  
 
You have been asked to pay a 20% coinsurance for outpatient mental health. This item/service falls within the 
outpatient mental health care 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 waive the coinsurance for outpatient 
mental health on April 18, 2023, to May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99255 billed for date of service January 31, 
2023. 
 
You asked the Plan to pay for procedure code 99255. You say that this was medically necessary.  The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99255 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99255 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99255 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99255 billed for date of service January 31, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medical services provided on May 3, 2023, billed with codes 99233 
and 93571. 
 
You asked the Plan to pay for the services as billed. You say that this was billed correctly based on the services 
rendered.  The Plan denied your request. The Plan says that 99233 was not billed with a valid primary 
diagnosis code, and 93571 is missing the required modifier.  
 
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. We have reviewed the documentation, and the Plan's arguments for the codes at 
issue. We find that the rationale for these two codes is not supported. For code 99233, we find that the primary 
diagnosis code listed, I21.4, is an appropriate primary diagnosis per guidelines. A code is not appropriate for a 
primary diagnosis if it is a manifestation code, with a Code first note. Diagnosis codes we "Use additional 
code" notes are etiology codes which are valid for a primary diagnosis. 
 
As for code 93571, this is an add-on code in relation angiography code 92928-RC. As the RC modifier is used 
with the primary code, it would not be required for the add-on code as these would both be related to the same 
anatomical structure. Therefore, we decided that the Plan has to pay for the medical services provided on May 
3, 2023, billed with codes 99233 and 93571.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87481, 87641, 87653, 87798) provided 
on January 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
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 lab services. Our reviewer says that the documentation 
does not support the codes billed. Our reviewer found the use of the XU modifier to denote separate services is 
not supported by the provided records. 
 
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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (87150, 87481, 87641, 87653, 87798) provided on January 23, 2023.
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 requested services are medically necessary. The 
Plan denied your request. The Plan says an admission to an IRF is not reasonable and 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that while the medical record supports 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. Our physician reviewer also found that 
there is not a reasonable expectation that this patient 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nivolumab (J9299) and ipilimumab (J9228).  
 
You asked the Plan to pre-approve nivolumab and ipilimumab. You say that the request is medically necessary. 
The Plan denied your request. The Plan says this request does not meet criteria for off-label use of anticancer 
drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 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 nivolumab and ipilimumab. Our 
reviewer says that the request is not medically necessary. Our physician reviewer found the combination of 
nivolumab and ipilimumab is only FDA approved as first line treatment of non-small cell lung cancer if their 
anaplastic lymphoma kinase (ALK) and epidermal growth factor receptor (EGFR) are negative. However, the 
enrollee has already progressed on first line treatment with immunotherapy with durvalumab. This off-label use 
is not supported by one of the major drug compendia or by clinical research and the service is not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nivolumab and ipilimumab have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nivolumab (J9299) and ipilimumab (J9228).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent testing (87481, 87500, 87640, 87652, 
87798, 87799, 87900). provided on April 12, 2023. 
 
You asked the Plan to pay for infectious-agent testing (87481, 87500, 87640, 87652, 87798, 87799, 87900).. 
You say that the services at issue were a medical necessity for the enrollee. 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 infectious-agent testing 
(87481, 87500, 87640, 87652, 87798, 87799, 87900). provided on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement (97598) provided May 18, 2023. 
 
You asked the Plan to pay for the service. You say that this was medically necessary  The Plan denied your 
request. The Plan says the primary procedure code 97597 was not paid; therefore, this add-on code is not 
payable. 
 
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 97598 is debridement (eg, high pressure waterjet 
with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, 
devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound 
assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) 
surface area; each additional 20 sq cm, or part thereof (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 service. Our reviewer found there is no documentation 
that support procedure code 97598. CPT code 97598 represents each additional 20 sq cm of tissue debrided (or 
partial thereof), (must be listed with primary procedure 97597 - debridement, open wound). No indication has 
been provided that the primary procedure code 97597 has been billed; therefore, billing of 97598 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the debridement (97598) provided May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 83520) rendered on 
November 8, 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 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 code 83520 is "Immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified." 
 
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 denied code represents "not 
otherwise specified." The medical record is not specific enough to verify the billed code. 
 
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 laboratory services (procedure code 83520) rendered on November 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307, G0480 and 83789 billed for date of 
service November 7, 2022. 
 
You asked the Plan to pay for procedure codes 80307, G0480 and 83789. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the provided 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 providers performing 
validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. 
 
We find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, the record 
indicates that a custom panel of tests was ordered. However, the order does not identify the tests that 
constituted the panel. 
 
We also decided that Medicare rules for coverage of procedure code 83789 have not been met. Specifically, we 
find that the testing described by the billed code is considered specimen validity testing which is not separately 
payable. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 80307, G0480 and 
83789 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 80307, 
G0480 and 83789 billed for date of service November 7, 2022.
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not reasonable and 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 the complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that they would meet criteria for admission to an IRF.  There is no indication that the enrollee 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain their functional status.  The 
member can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric services (90791 and 90785) provided July 7, 
2022. 
 
You asked the Plan to pay for the services. You say that the records support the primary diagnosis code that 
was billed.  The Plan denied your request. The Plan says the diagnosis code F01.50 has instructional note to 
code first the underlying condition. 
 
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 90791 is psychiatric diagnostic evaluation. The definition 
of code 90785 is interactive complexity (List separately in addition to the 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 found for code 90791, the documentation submitted was reviewed and does not meet criteria. The diagnosis reported for this procedure is, 
International Classification of Diseases (ICD) 10 F01.50 Vascular dementia, unspecified severity, without 
behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, however, diagnosis was not 
reported following ICD 10 guidelines. ICD 10 guidelines for this procedure code states, "Code first the 
underlying physiological condition or sequelae of cerebrovascular disease". In this case, the service was 
reported incorrectly. For code 90785, the documentation submitted was reviewed and does not meet criteria. 
The diagnosis reported for this procedure is, ICD 10 F01.50 Vascular dementia, unspecified severity, without 
behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, however, diagnosis was not 
reported following ICD 10 guidelines. ICD 10 guidelines for this procedure code states, "Code first the 
underlying physiological condition or sequelae of cerebrovascular disease". In this case, the service was 
reported incorrectly. 
 
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 psychiatric services (90791 and 90785) provided July 7, 2022.