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

 
We decided that the Plan does not have to pay for emergency room services (99285, 80053, 85025, 36415) 
provided on September 11, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the provider is not eligible for Medicare payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for emergency room services (99285, 
80053, 85025, 36415) provided on September 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305, 88342, and 88341 billed for date of 
service July 12, 2022. 
 You asked the Plan to pay for procedure code(s) 88305, 88342, and 88341. You say that you would like your 
claim reprocessed. The Plan denied your request. The Plan says these codes are included in the facility payment 
and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305, 88342, and 
88341. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88305, 
88342, and 88341. Based on this information, we decided that Medicare rules for coverage of procedure code 
88305, 88342, and 88341 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88305, 88342, and 88341 billed for date of service July 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 26, 
2023, to March 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were referred by a network provider. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 26, 2023, to March 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent testing (87636) provided on December 24, 
2022. 
 
You asked the Plan to pay for infectious-agent testing. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of infectious-agent 
testing have not been met. Therefore, we decided that the Plan does not have to pay for infectious-agent testing 
(87636) provided on December 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93313 billed for date of service February 13, 
2023. 
 You asked the Plan to pay for procedure code 93313. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 93313 is bundled into payment for code 00567. 
 
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 93313 
is a column II code to column I code 00567. 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 93313 billed for date of service February 13, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 26, 
2023 to March 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service February 26, 2023 to March 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 5, 2022, billed with 
procedure code 67108-80-LT. 
 
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 documentation does not support the billed code. 
This claim was billed with an incorrect modifier. 
 
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 67108-80-LT is Repair of retinal detachment; with 
vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, 
cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique. 
 
We find that CPT code 67108-80-LT is not supported in the medical record. Specifically, this procedure was 
billed with modifier 80, assistant at surgery by another physician. However, the documentation does not 
support that the provider listed on the claim actually performed these services as a different provider was listed 
as the assistant in the documentation provided.  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 August 5, 2022, billed with procedure code 67108-80-LT.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no magnetic resonance imaging 
(MRI) in the submitted records documenting modic changes without facet degenerative joint disease or 
foraminal stenosis. The cause of the enrollee's back pain is not clear. The records do not support that the 
Intracept procedure is reasonable and 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 an Intracept procedure.
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 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 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 medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show that your rehabilitation needs 
are complex. Services needed may be provided safely in a lower level of care. 
 
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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 0117U for date of service 
November 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary and is 
covered by Medicare. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. The Plan also says that you billed this claim with an 
incorrect Place of Service code. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. In addition, this claim was billed with the laboratory POS code. The records do not support that 
the sample was taken in a laboratory setting. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services billed with code 0117U for date of service November 17, 2022.
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 you need rehabilitation to recover before going 
home. The Plan denied your request. The Plan says you do not have complex rehabilitation needs. Services 
needed may be provided safely in a lower level of care. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroplasty surgery. 
 
You asked the Plan to pre-approve knee arthroplasty. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the record shows the enrollee does not have advanced joint disease 
on imaging, or a history of unsuccessful conservative therapy. 
 
The Plan follows Medicare rules. Medicare rules state that knee arthroplasty surgery may be covered under 
certain circumstances. 
 
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 knee arthroplasty. Our reviewer says 
that the enrollee does not meet criteria for this surgery. Our physician reviewer found the imaging provided 
does not corroborate advanced joint disease. Detailed documentation regarding a trial and failure of recent, 
reasonable, comprehensive, less-invasive conservative care measures for 3 months is not evident. There are no 
distinct structural abnormalities. The enrollee does have a history of previous joint replacement that failed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee arthroplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve knee arthroplasty surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional SafeRide mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says you are requesting an additional 32.3 miles for a 
total of 82.3 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 48 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 SafeRide mileage 
(A0170).
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 you need rehabilitation in order to support to get 
back to be on her own to return to home, and help with helping and standing up. The Plan denied your request. 
The Plan says your records show that it is not reasonable to expect that you will be able to safely participate in, 
or fully benefit from, the intensity of services of an IRF. You can safely receive the services you need in other 
settings, at a skilled nursing facility or perhaps home 
with home health services. 
 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 the Barostim NEO device (0266T). 
 
You asked the Plan to pre-approve the Barostim NEO device. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says placement of the Barostim Neo 
system is not medically necessary for this enrollee and is not a covered benefit. 
 
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 Barostim NEO device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Baroreflex stimulation devices have been considered potential alternative 
treatments for resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse 
generator implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one 
of the carotid arteries. In August 2019 the Food and Drug Administration (FDA) approved the system for use in 
patients with refractory heart failure who remain symptomatic despite treatment with guideline-directed 
medical therapy, are New York Heart Association (NYHA) Class III, have an ejection fraction less than 35%, 
and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement 
in normal daily activities, distance walked, quality of life, and improved cardiac levels biomarker levels. There 
remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not 
be considered medically reasonable and necessary in this enrollees clinical management. 
 
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 Barostim NEO device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim NEO device (0266T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12002 billed for date of service March 27, 
2023. 
 You asked the Plan to pay for procedure code 12002. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 12002 is bundled into payment for code 11602. 
 
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 12002 
is a column II code to column I code 11602. 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 12002 billed for date of service March 27, 2023.