Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on May 31, 2023. 
 
You asked the Plan to pay for a psychotherapy visit. You say that this was medically necessary and 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 a psychotherapy visit 
provided on May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on April 21, 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 code is part of the primary procedure and ineligible for separate payment. 
 
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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the 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 intraservice time, patient age 
5 years or older."  
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 CPT code 99152 is not supported. 
According to CPT and Medicare guidelines, there is a more appropriate code for moderate sedation provided 
during an endoscopic procedure, G0500. This should be reported instead of 99152. 
 
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 moderate sedation services (procedure code 99152) rendered on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an insertion of non-tunneled centrally inserted central venous 
catheter (36556) and ultrasound guidance for vascular access requiring ultrasound evaluation of potential 
access sites (76937) provided on April 23, 2023. 
 
You asked the Plan to pay for inserted catheter. You say that you disagree with the denial and have submitted 
medical records for review. The Plan denied your request. The Plan says codes 36556 and 76937 remains not 
supported.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for inserted catheter. Our reviewer says that the service does not 
meet criteria for payment on this claim. Our reviewer found the procedure report for CPT 36556 does not 
include sufficient documentation to meet Certified Professional Coder (CPC) guidelines for central venous 
access procedures. "To qualify as a central venous access catheter or device, the tip of the catheter/device must 
terminate in the subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava, or 
the right atrium" Procedure report documents "The enrollee placed in Trendelenburg position for procedure. 
right neck site then prepped and draped in usual sterile fashion. The enrollee was given 8 cubic centimeters (cc) 
of 1% lidocaine for local anesthetic. Using sterile sonosite guidance, vein then punctured on 1 attempt. Dark 
red blood was aspirated freely. Wire passed smoothly; catheter advanced".  In this case this procure cannot be 
verified. Our reviewer found that CPT 76937 does not include documentation to support ultrasound guidance 
for vascular access requiring ultrasound evaluation of potential access sites.  For CPT 76937, an ultrasound 
must be used for real-time visualization of vascular entry. It is not appropriate to code 76937 if the vessel is 
seen by ultrasound and marked, but ultrasound is not used to guide the needle entry. There must be 
documentation of the localization process in the medical record. There must be permanent recordings, image(s) 
of the chosen vein. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inserted catheter have not been met. Therefore, we decided that the Plan does 
not have to pay for an insertion of non-tunneled centrally inserted central venous catheter (36556) and 
ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites (76937) 
provided on April 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the use of non-invasive therapy 
during daily exertion with mobility will allow the patient to increase daily activity levels and work toward 
overall better physical health and mental health. The Plan denied your request. The Plan says a home ventilator 
is not medically necessary for this patient because their needs can be met with an alternative device such as a 
BiPAP device with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the patient 
was admitted with COPD exacerbation and initially failed BiPAP therapy. The patient also required intubation 
and following appropriate best practice therapy was then extubated and transferred out of the intensive care 
unit. However, there is no documentation of requiring a BiPAP or BiPAP with AVAPS following extubating or 
transfer out of the intensive care unit. Also, there is no documentation or data to suggest that the patient cannot 
and does not tolerate a BiPAP. While there is severe COPD a BiPAP with or without AVAPS is a best practice 
starting point to initiate for the patient. Therefore, the request does not meet the coverage criteria. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on May 4, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee is bed 
confined, confused, experiencing dizziness and requires a bariatric stretcher to be transported. You also say that 
due to the enrollee's condition at the time of transport, any other means of transport would be unsafe  The Plan 
denied your request. The Plan says the ambulance transportation from the hospital to the enrollee's assisted 
living facility was not medically necessary.  
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service and ground mileage. 
Our reviewer says that the ambulance services were not medically necessary.  Our physician reviewer found the transportation via ambulance from the emergency department to the 
enrollee's assisted living facility was not medically necessary. The enrollee did not require the expertise of 
trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. 
Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) 
without endangering the enrollee's condition. A prudent person would not believe that immediate medical 
attention was required for someone who was being discharged from the emergency department/hospital. 
 
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 ambulance service and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on May 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
January 28, 2023, through February 21, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on January 28, 2023, through February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 17, 2023, billed with 
procedure code 58300. 
 
You asked the Plan to pay for the practitioner services provided. You say that the clam is billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
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 58300 is Insertion of intrauterine device (IUD). 
 
We find that CPT code 58300 is not supported in the medical record. Specifically, the billed code has a status 
indicator N and is not covered by Medicare. 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 April 17, 2023, billed with procedure code 58300.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service March 3, 
2023. 
 You asked the Plan to pay for procedure code 99213. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99213 is bundled into payment for code 99214. 
 
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, we have confirmed that code 99213 
is a column II code to column I code 99214. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99213 billed for date of service March 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LinQ sacroiliac joint stabilization system (0775T). 
 
You asked the Plan to pre-approve the LinQ system. You say that this procedure has been proven to be safe and 
effective through numerous peer-reviewed studies. The Plan denied your request. The Plan says this device is 
considered experimental. 
 
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 LinQ system. Our reviewer says 
that the requested LinQ system is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the detailed documentation is not evident regarding a clear history of SI joint pain 
onset. Multiple other plausible pain generators including at the lumbosacral spine are evident. There are limited 
large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested LinQ sacroiliac joint (SIJ) stabilization 
system 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 LinQ system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the LinQ sacroiliac joint stabilization system (0775T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine decompression surgery. 
 
You asked the Plan to pre-approve spine decompression surgery. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this 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 spine decompression surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has Parkinson's disease. Physical examination does not 
correlate with injury. There is no report of injection therapy providing significant relief. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spine decompression surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve spine decompression surgery.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you need additional transportation and 
request reconsideration. The Plan denied your request. The Plan says you are requesting an additional 17.1 
miles for a total of 67.1 miles and your benefit only allows 50 miles. The Plan also says you have exceeded 
your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 72 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 7, 2022, to 
February 5, 2022. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of home health services have been met. 
Specifically, there is no Plan of Care present in the case record for the dates of service at issue. Therefore, we 
decided that the Plan does not have to pay for home health services provided from January 7, 2022, to February 
5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevator. 
 
You asked the Plan to pre-approve the power seat elevator. You say that your muscle strength and stamina are 
not anywhere near enough to get you very far by yourself. You say that you generally have an aide to help you. 
You also say that you would like to feel like you still have some independence. The Plan denied your request. 
The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that power seat elevation equipment is reasonable and 
necessary for individuals using complex rehabilitative power-driven wheelchairs when certain criteria have 
been met. 
 
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 power seat elevator. Our reviewer 
says that the requested power seat elevator is not medically necessary. Our physician reviewer found the 
provided documentation does not indicate that the enrollee has a non-weight bearing transfer. The 
documentation does not live in a home environment requiring her to reach in order to complete MRADLs. 
Therefore, the reviewer found that the requested power seat elevator 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 power seat elevator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat elevator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdomen x-ray provided on March 24, 2023. 
 
You asked the Plan to pay for an abdomen x-ray. You say that this was medically necessary and 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 an abdomen x-ray 
provided on March 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear implant. 
 
You asked the Plan to pre-approve a cochlear implant. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that cochlear implants are covered for the indications 
established in the applicable NCD.  
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 cochlear implant. Our reviewer says 
that the requested cochlear implant is not medically reasonable and necessary. Our physician reviewer found 
that the provided records do not document a diagnosis of bilateral moderate-to-profound sensorineural hearing 
impairment with limited benefit from appropriate hearing (or vibrotactile) aids, as required by the NCD. 
 
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 cochlear implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a cochlear implant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service February 13, 
2023. 
 You asked the Plan to pay for procedure code 99284. You say that the enrollee was seen for a medically 
necessary procedure. The Plan denied your request. The Plan says payment for code 99284 is bundled into 
payment for code 99285. 
 
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, we have confirmed that code 99284 is a column II code to column I code 99285. Code 99285 has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99284 
billed for date of service February 13, 2023.