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

 
We decided that the Plan does not have to pre-approve ViviGen allograft (20930). 
 
You asked the Plan to pre-approve ViviGen allograft. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of ViviGen allograft in the setting of spinal 
fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 ViviGen allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are 
needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ViviGen allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ViviGen allograft (20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36247 billed for date of service March 28, 
2022. 
 
You asked the Plan to pay for procedure code 36247. You say that all billed procedures were performed and 
were medically necessary. The Plan denied your request. The Plan says payment for code 36247 is bundled into 
payment for code 37227-LT. 
 
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 36247 
is a column II code to column I code 37227-LT. 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 36247 billed for date of service March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 11, 2022, billed with 
codes 93040, 93790, A4615, A4930, 36000, 99070, and 99072. 
 
You asked the Plan to pay for the services as billed. You say that this is billed correctly and should be paid.  
The Plan denied your request. The Plan says the claim processed correctly.  
 
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 definition of CPT code 93790 is ambulatory blood pressure monitoring, utilizing report-generating 
software, automated, worn continuously for 24 hours or longer; review with interpretation and report. This is 
not supported as the blood pressure monitoring did not occur for at least 24 hours, and there was no 
interpretation and report. 
 
Code 93040 is a column II code in relation to column I code 99152. Although modifier -59 was used, there is 
no evidence that this service was distinct from the moderate sedation. In addition, the code definition includes 
an interpretation and report, which is not present in the record.  
 
Codes 36000, 99070, and 99072 have a status indicator of B in the Physician Fee Schedule. This means no 
separate payment can be made for these services.  
 
Code A4615 and A4930 have a status indicator of X in the Physician Fee Schedule. These can only be paid as 
supplies related to durable medical equipment. Such items can only be reimbursed when provided for use in the 
home. These were supplies used in the provider's office and are not separately reimbursed. 
 
Based on this information, we find that the coverage rules for the services as billed have not been met.  
Therefore, we decided that the Plan does not have to pay for the medical services provided on May 11, 2022, 
billed with codes 93040, 93790, A4615, A4930, 36000, 99070, and 99072.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an office visit with an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the OON office visit. You say that the requested OON provider would 
provide the best course of treatment for your symptoms. You say that the requested OON provider is most 
suitable for your treatment because of her extensive experience and knowledge in this field.  The Plan denied 
your request. The Plan says that they have network providers who can supply the care needed.  
 
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 provide any medical records or evidence of having 
made reasonable attempts to obtain medical records. This missing information is necessary for us to review 
whether or not there is a comparable care issue and whether or not the network provider can sufficiently treat 
your condition/needs.  Therefore, we decided that the Plan has to pre-approve an office visit with an out-of-
network (OON) provider.   
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says according to the available records, the member does not meet all the required Medicare 
criteria for admission to an Inpatient Rehabilitation Facility. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the chiropractic services. You say that the care with this out-of-network 
provider has made significant improvement in your health. The Plan denied your request. The Plan says you 
must receive your care from a network provider. 
 
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 network providers 
available who 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 
the chiropractic services to be provided by an out-of-network (OON) provider.
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 needs continued daily physician 
oversight in an IRF setting for medical management as well as aggressive therapy and wound care. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatments 
(98940) and the office visits (99211, 99212, 99213) provided from January 17, 2023, through March 16, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a  
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the chiropractic 
manipulative treatment services provided were not medically necessary. Additionally, the chiropractic office 
visits provided are not a covered benefit by Medicare or the Plan.  
  
 
 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care. The rules also says that the only chiropractic service Medicare covers is manual manipulation of the spine 
to correct a subluxation.   
 
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 these services. Our reviewer says that the 
chiropractic services provided in this case were not medically necessary. Our physician reviewer found that in 
this case, the record indicates that you have chronic cervical neck pain causing migraine headaches. The 
records provided do not document the presence of a subluxation of the spine either by physical examination or 
radiographic images. The records of these visits do not support progressive improvement of symptoms but 
rather maintenance therapy for a chronic condition. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the chiropractic services provided. The elements 
of the coverage criteria are not satisfied.   
 
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 issue reimbursement for the chiropractic manipulative treatments (98940) and the office visits (99211, 
99212, 99213) provided from January 17, 2023, through March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953 x 
2). 
 
You asked the Plan to pre-approve bone replacement graft. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement graft for ridge preservation (D7953 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thyroid stimulating hormone testing billed with code 84443 
for date of service February 9, 2023. 
 
You asked the Plan to pay for code 84443. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this test is not covered because it was done for screening 
purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, code 84443, was requested solely for screening purposes. You only billed this 
test with a screening diagnosis. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pay for thyroid stimulating hormone testing billed with code 84443 for 
date of service February 9, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve the physical therapy visits. The Plan denied your request. The Plan says 8 
additional physical therapy visits are medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy.  

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 physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has previously been treated with 
outpatient therapies and should be independent with a home exercise program. The enrollee has no recent 
injury or a decline in function. The additional therapy services are not appropriate duration and frequency for 
treatment of the enrollee's medical condition and therefore are 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 physical therapy visits. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with codes 82607 and 83036 provided on 
October 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that these were ancillary services, and the claim should 
be processed as in-network. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services billed with codes 82607 and 83036 provided on October 13, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim complete maxillary denture (D5810) provided on 
October 6, 2022, to December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within the enrollee's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an interim 
complete maxillary denture (D5810) provided on October 6, 2022, to December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84436 and 84480 billed for date of service 
December 6, 2022.  
 
You asked the Plan to pay for procedure codes 84436 and 84480. You say that the physician ordered these lab 
tests, so they should be covered. The Plan denied your request. The Plan says payment for codes 84436 and 
84480 are bundled into payment for codes 84339 and 84481. 
 
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 codes 
84436 and 84480 are column II codes to column I codes 84339 and 84481 with a modifier indicator of 0. The 
column II codes are therefore not payable. 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 84436 and 84480 billed 
for date of service December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit provided on September 26, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that the provider relies on the facility staff to 
obtain the necessary authorizations. You also say that the provider rendered this medically necessary service to 
the enrollee in good faith. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that 
the Plan does not have to pay for the psychotherapy visit provided on September 26, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and closure of tear duct opening 
using plug (68761) provided on November 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that the services should be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99214) and closure of tear duct 
opening using plug (68761) provided on November 2, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided on January 18, 2023. 
 
You asked the Plan to pay for the home health services. You say that these home health services were denied 
out of the blue, and you have received no reimbursement for them.  You need to continue to receive care, so 
this claim needs to be paid. The Plan denied your request. The Plan says that the provider billed with an 
incorrect type of bill code. 
 
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's sole rationale for denial is that the provider billed with an 
incorrect type of bill code.  However, the Plan has failed to explain what, exactly, is wrong with the code.  The 
Plan has failed to identify what the correct type of bill code should be for this service. Lastly, it does not appear 
that the Plan has made any efforts to contact the provider to ask them to correct the billing, if indeed a billing 
error exists.  The burden is on the Plan to show why its denial is correct.  By failing to provide this information, 
we find that the Plan has not met this burden. Therefore, we decided that the Plan has to pay for home health 
services provided on January 18, 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.