Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from June 30, 2022, to July 7, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered. The Plan 
denied your request. The Plan says that this charge exceeds the fee schedule, maximum allowable or contract or 
legislated fee arrangement. 
 
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. Specifically, the Plan did not provider a copy of the Evidence of Benefits (EOB). 
Without this information we cannot determine the services that are being denied or why they are being denied. 
Therefore, we decided that the Plan has to pay for the home health services provided from June 30, 2022, to 
July 7, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous basivertebral nerve ablation at 
L5 and S1. 
 
You asked the Plan to pre-approve a surgery. You say that this procedure is medically necessary for the 
enrollee. The Plan denied your request. The Plan says enrollee does not need this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an Intracept intraosseous basivertebral nerve ablation at L5 and S1.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint nerve destruction. 
 
You asked the Plan to pre-approve the procedure. You say that the enrollee has cervicalgia and cervical 
radiculopathy that is worsening over time. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the enrollee must have at least 2 medically reasonable 
and necessary diagnostic medial branch blocks (MBBs), with each one providing a consistent minimum of 80% 
sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used. 
 
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 procedure. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has had 2 bilateral C4-C5 
and C5-C6 diagnostic injections. The first one is noted in the progress notes to have given 30% pain relief. The 
LCD requires that both sets of diagnostic blocks produce 80% pain relief, which was not achieved. 
 
 
  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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint nerve destruction.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires more intensive therapy to 
improve mobility. The Plan denied your request. The Plan says the IRF services you are requesting do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuromuscular electrical stimulation. 
 
You asked the Plan to pre-approve neuromuscular electrical stimulation. You say that this is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules state that neuromuscular electrical stimulation is only covered 
if certain criteria are 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 neuromuscular electrical stimulation. 
Our reviewer says that the enrollee does not meet criteria for this procedure. Our physician reviewer found for 
this device to be clinically meaningful and for the enrollee to meet criteria for such use, they must have an 
intact nerve supply to the brain, muscle, and spinal cord. However, as multiple sclerosis involves all of these 
areas, there is not an intact nerve supply for this enrollee as required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuromuscular electrical stimulation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve neuromuscular electrical stimulation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical facet joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve a cervical facet joint RFA. You say that you are in extreme pain and cannot 
sleep at night due to the pain. You say you cannot walk and need the procedure. The Plan denied your request. 
The Plan says criteria for the cervical facet joint radiofrequency ablation procedure have not been met.  
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. The rules say that cervical facet joint radiofrequency ablation is not considered 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 cervical facet joint RFA. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you have not had two 
sets of diagnostic medial branch blocks at the requested cervical anatomic site, and you have not undergone a 
prior RFA procedure at the site. Therefore, the request for cervical facet joint RFA 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 a cervical facet joint RFA have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a cervical facet joint radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service January 19, 
2023. 
 You asked the Plan to pay for the billed services. You say that the claim denied incorrectly. The Plan denied 
your request. The Plan says an inappropriate primary diagnosis code was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99232 was billed with primary diagnosis code R65.20. This diagnosis code as a code 
first notation, which means it is not permitted to be used as the primary diagnosis code. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99232 billed for date of service January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for date of service November 
25, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says there was a failure to provide the requested documentation. 
 
 
 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. In this case, there are no medical records to show that the billed 
services were actually provided, coded correctly, and medically necessary. The case file does show that the 
Plan made several attempts to obtain additional information with no success. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99239 billed for date of service November 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99204) provided on February 3, 
2023. 
 
You asked the Plan to pay for the outpatient office visit. You say that you had to go to a doctor in New York 
for your sleep apnea because you have to stay with your mother who fell and broke her hip, to take care of her. 
You also say that you were not aware that you needed prior authorization for this visit. The Plan denied your 
request. The Plan says this service was rendered by an OON provider. The Plan also says that there was no 
prior authorization requested or granted for these services, the care provided was not urgent or emergent and 
there are in network providers that can provide this service. 
 
 
 Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the outpatient office visit. Our reviewer says 
that the outpatient office visit was not medically reasonable and necessary. Our physician reviewer found the 
review indicates that you self-referred for septoplasty. The evaluation revealed deviated septum to the left with 
right inferior turbinate hypertrophy. Our reviewer found that you requested a sleep study. The review has 
determined you could have foreseen requiring the services prior to leaving your service area. Our physician 
reviewer also found that the care provided (or requested) was medically necessary but it would have been 
medically reasonable to delay the services until you returned to your service area. 
 
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 outpatient office visit have not been met. Therefore, we decided that the 
Plan does not have to pay for the outpatient office visit (99204) provided on February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint interventions. 
 
You asked the Plan to pre-approve facet joint interventions. You say that this is needed so the enrollee no 
longer has to suffer pain. The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint interventions are only covered if certain 
criteria are 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 facet joint interventions. Our reviewer 
says that the enrollee does not meet criteria for this procedure. Our physician reviewer found the enrollee has 
received 3 therapeutic facet injections. However, there is no documentation as to why the enrollee cannot have 
radiofrequency ablation (RFA). 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 facet joint interventions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint interventions.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service December 
19, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee's insurance information is not 
known until the specimen arrives. The Plan denied your request. The Plan says the records do not support the 
billed code. 
 
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 G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
15-21 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
G0482 billed for date of service December 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bendeka. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the requested treatment order of Bendeka is not medically necessary.  
 
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 the medication. Our reviewer says that 
the requested use of Bendeka is not FDA approved for the enrollees diagnosis. Our physician reviewer found 
that the use of Bendeka is also not supported by one of the major drug compendia or by clinical research. 
 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Bendeka.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 23, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 23, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0491, A4657 and Q4081 billed for dates 
of service from January 27, 2023, to January 30, 2023. 
 
You asked the Plan to pay for procedure codes G0491, A4657 and Q4081. You say that the services at issue 
have been billed 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 modifiers are required with ESRD Billing for 
reporting the adequacy of dialysis and the vascular access. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure codes G0491, A4657 and Q4081 have not been met. Specifically, the services at issue 
have not been reported with the required modifier(s). Therefore, we decided that the Plan does not have to pay 
for procedure codes G0491, A4657 and Q4081 billed for dates of service from January 27, 2023, to January 30, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99223) billed for date of service January 16, 
2023. You asked the Plan to pay for hospital care. You say that this service was billed appropriately for separate 
payment. The Plan denied your request. The Plan says this care is included in the global surgery period of code 
93653 which was billed for the same date of service. This code was not submitted with an appropriate modifier 
for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that modifier 25 is used to facilitate billing of evaluation and management services on the day of a 
procedure for which separate payment may be made. The -57 modifier is not used with minor surgeries 
because the global period for minor surgeries does not include the day prior to the surgery.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hospital care have not been met. Specifically, code 99223 was billed with modifier 57 and was 
reported on the same claim as the primary procedure, 93653. Code 93653 has a global surgery indicator of 000, 
indicating that it is a minor surgical procedure or an endoscopy. It is therefore inappropriate to report code 
99223 with modifier 57 in this case. Therefore, we decided that the Plan does not have to pay for hospital care 
(99223) billed for date of service January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power scooter (E1399) provided on March 28, 2022. 
 
You asked the Plan to pay for the power scooter. You say that you contacted the Plan and were advised to buy 
the scooter and the Plan would reimburse you. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 
  The record does not contain a valid physician order to support the medical necessity for the supplies provided 
in this case. Specifically, a home evaluation was not performed. The records do not show your home provides 
adequate access between rooms, maneuvering space, and surfaces for the operation of the scooter that is 
provided. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the power scooter (E1399) provided on 
March 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for date of service November 18, 
2022, to December 17, 2022. You asked the Plan to pay for the billed services. You say that there were problems with your billing software. 
The Plan denied your request. The Plan says the NOA was not received timely. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 20, 2022. The NOA was not received by the Plan until March 8, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
date of service November 18, 2022, to December 17, 2022.