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

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 rendered on February 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 these charges are not reimbursable separately. 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the laboratory report does not 
include documentation to support the use of modifier XU that was billed. There is no documentation of an 
unusual non-overlapping service.  
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 87481 and 87653 rendered on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) services. 
 
You asked the Plan to pre-approve the services. You say that the records provided support the need for the 
requested treatment. The Plan denied your request. The Plan says medical studies have not shown that this is 
the best treatment for the enrollee's specific condition. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that while SBRT can potentially provide better pain and local control in this patient with painful spinal 
metastasis, it is not considered the first standard of care palliative radiation treatment in this situation. 
Therefore, it 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve stereotactic body radiation therapy (SBRT) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept basivertebral nerve ablation procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is a procedure that will help the 
enrollee's back pain. The Plan denied your request. The Plan says this treatment is not proven effective at this 
time. 
 
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 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 central canal stenosis and disc bulging and other degenerative changes 
on spinal imaging which may be the cause of the patients back pain. Provided records in this case do not 
document the Intracept procedure is safe and effective, not mainly for the convenience of the patient or the 
physician, not experimental or investigational, is appropriate, is furnished in accordance with accepted 
standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function 
of a malformed body member, is furnished in a setting appropriate to the patient's medical needs and condition, 
is ordered and furnished by qualified personnel, is one that meets, but does not exceed, the patient's medical 
need and is at least as beneficial as an existing and available medically appropriate alternative as required by 
the Social Security Act, Section 1862. 
 
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 basivertebral nerve ablation procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for virtual care services provided on August 31, 2022. 
 
You asked the Plan to pay for the virtual care services. You say that the provider is enrolled under the patients 
benefit plan and the services are necessary for the patient. The Plan denied your request. The Plan says virtual 
care services are not covered out-of-network. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) are not covered 
out-of-network. 
 
The requested provider in this case is not a network provider with the Plan. The Plan says that virtual care (also 
referred to as telehealth services, virtual check-ins or eVisits) is not covered out-of-network. The Plan did not 
pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for virtual care services provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for virtual care services provided on September 29, 2022. 
 
You asked the Plan to pay for virtual care services. You say that per the records, the provider is enrolled under 
the patient's benefit plan and the services are necessary for the patient. The Plan denied your request. The Plan 
says no benefit coverage is available for virtual services performed by an out-of-network provider. The Plan's 
authorization portal did not contain an authorization on file approving these services. 
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) are 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover virtual care out-of-
network. Based on this information, we decided that the Plans rules for coverage of virtual care services have 
not been met. Therefore, we decided that the Plan does not have to pay for virtual care services provided on 
September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 rendered on 
February 22, 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 these charges are not reimbursable separately. 
 
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 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique  
CPT 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
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 laboratory report does not 
include documentation to support an unusual non-overlapping service for any of these codes. Therefore, 
modifier XU cannot be verified. 
 
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 87481, 87653, and 87798 rendered on February 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Sprint peripheral nerve stimulator 
(PNS). 
 
You asked the Plan to pre-approve the PNS placement. You say that the enrollee is in need of this stimulator 
due to chronic lumbar pain. You also say that the enrollee has had multiple injection and abrasion procedures. 
The Plan denied your request. The Plan says the PNS is not being used to assess the enrollee's suitability for 
permanent placement. The Plan also says there is no clear support for using Sprint PNS for chronic pain. 
 
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 PNS placement. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered investigational for low back pain. There is an ongoing clinical trial for PNS in the setting of chronic 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 the PNS placement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve placement of the Sprint peripheral nerve stimulator (PNS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 rendered on April 
4, 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 96365: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour  
CPT 96366: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(List separately in addition to code for primary procedure) 
 
CPT 96521: 
 
Refilling and maintenance of portable pump 
 
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 procedure report describes 
intravenous insulin treatment for an outpatient. In this case, CPT 96365 and CPT 96366 are not verified as 
there is a more appropriate code to use for the services provided. In terms of CPT 96521, this procedure is not 
documented 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 96365, 96366, and 96521 rendered on April 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 rendered on February 8, 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 these charges are not reimbursable separately. 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the laboratory report does not 
include documentation to support the modifier reported (XU), and therefore it cannot be verified. 
 
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 87798 rendered on February 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure codes 87899, 87900, 87798) 
rendered on June 7, 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 this was incorrectly coded. 
 
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 87899: 
 
Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; not otherwise 
specified  
CPT 87900: 
 
Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
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 87798, the 
provider billed 19 units of this code. The Medically Unlikely Edits (MUE) for this code is 13. The records do 
not contain documentation to confirm the reason for the additional units being billed. In terms of CPT 87900, 
the laboratory report describes urinary tract infection panel (UTIP) and polyMIC testing was performed using 
real time CR (Molecular) polyMIC antibiotic sensitivity testing. There is a more appropriate code to use for 
this testing. Finally, the procedure report does not include sufficient documentation to verify infectious agent 
antigen detection by immunoassay with direct optical observation. Therefore, CPT 87899 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 laboratory services (procedure codes 87899, 87900, 87798) rendered on June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve bilateral partial foot prosthetic inserts. 
 
You asked the Plan to pre-approve the partial foot inserts. You say that the enrollee has had all ten toes 
amputated and requires these inserts for balance and stability. The Plan denied your request. The Plan says that 
no review of the appeal request was performed.  
 
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. The Plan has not provided a valid appeal denial rationale in this case. The 
original denial was due to lack of medical records. Such records were received but not reviewed by the Plan. 
Therefore, we decided that the Plan has to pre-approve bilateral partial foot prosthetic inserts.  
 
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 procedure codes 87150, 87481, 87641, 87653, and 87798 
rendered on February 22, 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 87150: 
 
Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed 
 
CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 
CPT 87641: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, 
amplified probe technique 
 
CPT 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
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 the provider reported these procedures 
with the appended modifier XU - unusual non-overlapping services. However, the laboratory report does not 
include documentation to verify that any of the codes were unusual non-overlapping services. 
 
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 87150, 87481, 87641, 87653, and 87798 rendered on February 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the OON chiropractic care. You say that you have grade 5 spondylolisthesis 
and this is very painful.  You stated that there are no in-network chiropractors in your area, and you cannot 
travel by car for long periods of time. The Plan denied your request. The Plan says you do meet criteria for 
coverage of chiropractic treatment.  However, the requested provider is out-of-network and has not agreed to 
work with the Plan.  The Plan has identified two chiropractors in your local area that work with your current 
network and would be able to see you. 
 
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 providers who work 
with the Plan who are available and can provide the items/services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic care 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 pay for code 99236 billed for date of service July 28, 2022. 
 
You asked the Plan to pay for code 99236. You say that the medical records support the claim as billed. The 
Plan denied your request. The Plan says code 99236 is not supported by the medical record. The medical 
records don't support a comprehensive history. 
 
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 99236 is Hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 85 minutes must be met or exceeded. 
 
 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 code 99236. Our reviewer says that code 99236 is not 
supported by the medical record. Our reviewer found the patient was a 88-year-old woman with a history of 
atrial fibrillation, neuropathy, and recent leg fracture with open repair who presented with concern for infection 
of the surgical site. The medical documentation supports an appropriate exam, but not an appropriate history or 
medical decision making of a high level. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99236 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99236 billed for date of service July 28, 2022.