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

 
We decided that the Plan does not have to pay for drug testing (G0483) provided on March 14, 2023. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says there is insufficient information to corroborate the 
necessity of these services. 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 drug testing have been met. 
Specifically, no physician order or test requisition was included in the records provided, and the limited 
physician notes do not describe any specific intent for these services to be performed.. Therefore, we decided 
that the Plan does not have to pay for drug testing (G0483) provided on March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64448 and 64450 billed for date of service 
February 22, 2023. 
 
You asked the Plan to pay for procedure codes 64448 and 64450. You say that the services indicate the 
introduction of an anesthetic agent. The Plan denied your request. The Plan says payment for codes 64448 and 
64450 are bundled into payment for code 01400. 
 
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 64448 and 64450 is a column II code to column I code 01400. The 
medical records provided do not show that the services billed with the -59 modifier were separate and distinct 
procedural services. 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 codes 64448 and 64450 billed for date of service 
February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes E0673 and E0675 billed for date of service 
October 4, 2022. 
 
You asked the Plan to pay for the billed services. You say that this device was provided for use during the 
patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a procedure is 
not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 We find that the durable medical equipment was provided in an ambulatory surgical center. Although the items 
may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we 
decided that the Plan does not have to pay for procedure codes E0673 and E0675 billed for date of service 
October 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99214 billed for date of service February 22, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services are deemed payable. The Plan 
denied your request. The Plan says that the diagnosis codes should not be billed together. 
 
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 file shows that CPT code 99214 was billed with diagnosis code G56.03, carpal tunnel syndrome, bilateral 
upper limbs; and M54.17, radiculopathy, lumbosacral region. Diagnosis code G56 has an Excludes1 note that 
excludes current traumatic nerve disorder  see nerve injury by body region. We find that the two diagnosis 
codes are conditions that are unrelated to each other. Based on this information, we decided that Medicare rules 
for coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for procedure 
code 99214 billed for date of service February 22, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 27, 2023, billed with 
procedure code 99212. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. The billed service was reported with one or more diagnosis code pairs that are subject to an Excludes1 note. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on March 27, 2023, billed with procedure code 99212.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on March 
13, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. 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 $35 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $35 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 copayment 
for a specialist office visit provided on March 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve. 
 
You asked the Plan to pre-approve the thermal destruction of intraosseous basivertebral nerve. You say that the 
enrollee has tried and failed conservative treatment for chronic back pain. The Plan denied your request. The 
Plan says according to their own guidelines, medical criteria was not 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 the thermal destruction of intraosseous basivertebral nerve. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident 
regarding modic changes on the formal magnetic resonance imaging (MRI) from April 13, 2023, at the L4, L5, 
and S1 levels. Additionally, there were/are multiple plausible pathologic sources of significant pain generation.  
 
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 thermal destruction of intraosseous basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the thermal destruction of intraosseous 
basivertebral nerve.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and the coinsurance for the pontic (D6245) for 
tooth #30 provided on April 13, 2023. 
 
You asked the Plan to waive the copayment and the coinsurance for the pontic. You say that the procedures 
were necessary and a 3-unit bridge. The Plan denied your request. The Plan says this cost sharing was charged 
correctly for the pontic and there was no enrollee responsibility assessed for the retainer crowns. 
 
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 $10 
copayment for an office visit per visit for all non-Medicare covered services and you must pay a 50% 
coinsurance for each major dental service. 
 
The total allowed amount for the pontic (D6245) was $720 and the coinsurance was $360 ($720 allowed x 50% 
coinsurance). The total copayment amount for the pontic was $10. The total liability you have for the pontic 
(D6245) was $370 ($360 coinsurance + $10 copayment). 
 
You have been asked to pay a $10 copayment and a 50% coinsurance for the pontic. This item/service falls 
within the Dental services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment and the 
coinsurance for the pontic (D6245) for tooth #30 provided on April 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD) (E0483). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the Vest is medically necessary to help the 
enrollee manage their lifelong chronic lung disease. The Plan denied your request. The Plan says based on 
Medicare guidelines, the high frequency chest wall oscillation air-pulse generator system (HFCWO) requested 
does not meet the requirements for approval. 
 The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. 
This means that you do not have a medical condition for which a high frequency chest wall oscillation devise 
can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a 
high frequency chest wall oscillation device (HFCWOD) (E0483).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Optimizer Smart cardiac contractility modulation 
(CCM). 
 
You asked the Plan to pre-approve the CCM. You say that this is medically necessary for the enrollee. You also 
say that there are no other treatment options for the enrollee. The Plan denied your request. The Plan says this 
system is considered investigational or 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 CCM. Our reviewer says that the 
requested CCM is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, 
controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. Therefore, the reviewer found that the 
requested CCM 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 CCM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Optimizer Smart cardiac contractility modulation (CCM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care 
and is currently unstable for transfer. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
January 30, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says this item is not covered for 
the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 is used only for 
peripheral artery disease. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pneumatic compression device have not been met. The record does not show this device was 
ordered for the treatment of peripheral artery disease. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (E0675) provided on January 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0667, E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you are 
appealing to review the coverage denial of coverage of a Flexitouch PCD for the treatment of the enrollee's 
lymphedema. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an 
advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of 
either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0667, E0656).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says this injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the diagnostic SIJI should provide a minimum of 
75% relief of primary (index) pain with the diagnostic SIJI was measured by the same pain scale at baseline. 
The measurements of pain must be taken pre-injection on the day of the SIJ injection, post-intervention on the 
day of the injection, and the days following the injection to substantiate and corroborate the pain scores 
consistent with the pain relief for the duration of the local anesthetic and/or steroid 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 injection. Our reviewer says that the 
requested SIJ injection is not medically necessary. Our physician reviewer found the provided documentation 
does not support that the enrollee had 75% pain relief from the previous injection, as required by the 
guidelines. Therefore, the reviewer found that the request for a repeat SIJ 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint (SIJ) injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe obesity, 
lymphedema, heart failure with preserved ejection fraction (HFpEF), chronic methadone use, and obesity 
hypoventilation syndrome. She was recently hospitalized and the arterial blood gas (ABG) study was consistent 
with acute on chronic hypercarbic respiratory failure. The records do not show that she has been treated with 
outpatient bi-level positive airway pressure (BiPAP) therapy with or without average volume-assured pressure 
support (AVAPS). Medicare does not cover a home ventilator for the treatment of obesity hypoventilation 
syndrome or when used at settings that can be provided with BiPAP. The home ventilator is not reasonable or 
medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (POV) 
(K0800). 
 
You asked the Plan to pre-approve a group 1 standard POV. You say that you only have one leg and are getting 
tired of walking with crutches. You also say that you are getting too tired to walk with crutches. The Plan 
denied your request. The Plan says this request is not medically necessary because the records do not show that 
you do not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair 
in the home to perform MRADLs during a typical day. The Plan also says there is no documentation of a home 
evaluation, seating and mobility evaluation that shows you are able to operate, transfer onto and off of the 
POV. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 group 1 standard POV. Our reviewer 
says that you do not meet the criteria for coverage. Our physician reviewer found you are able to weed whack 
with crutches, and your current scooter is aging. Our reviewer also found that you are able to manage 
MRADLs with a manual wheelchair. 
 
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 group 1 standard POV have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 1 standard power operated vehicle (POV) (K0800).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot be safely discharged home 
without a continuous positive airway pressure machine and additional stair training. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuation of SNF care.