Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve venous ablation with sclerosant and ablation therapy. 
 
You asked the Plan to pre-approve venous ablation with sclerosant and ablation therapy. You say that the 
enrollee needs this procedure. The Plan denied your request. The Plan says the requested procedure is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that surgical treatment and sclerotherapy is indicate for 
those that have completed conservative therapy, is symptomatic, and the treatment of spider 
veins/telangiectasis will be considered medically necessary only if there is associated hemorrhage. 
 
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 venous ablation with sclerosant and 
ablation therapy. Our reviewer says that the requested venous ablation with sclerosant and ablation therapy are 
not medically necessary. Our physician reviewer found the provided documentation does not indicate that the 
enrollee has completed conservative therapy. The reviewer found that the documentation does not indicate that 
there is an absence of reported symptoms. Therefore, the reviewer found that the requested endovenous 
sclerosant and ablation therapy 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 venous ablation with sclerosant and ablation therapy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve venous ablation with sclerosant and ablation 
therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on 
August 7, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, this service was billed on the 
same date of service as minor surgery procedure 30903 (Control nasal hemorrhage, anterior, complex 
(extensive cautery and/or packing) any method). Without an appropriate modifier, this means this procedure is 
included in the global surgical period of the minor procedure and is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 
provided on August 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 13, 2022, billed with 
codes 81201, 81162, 81292, 81295, 81298, 81307, 81317, 81321 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and was reported 
with payable codes. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 13, 2022, billed with codes 81201, 81162, 81292, 81295, 81298, 81307, 81317, 81321 and 81351.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heart catheterization and ventriculography. 
 
You asked the Plan to pre-approve heart catheterization and ventriculography. You say that the requested heart 
catheterization and ventriculography is medically necessary. The Plan denied your request. The Plan says the 
requested heart catheterization and ventriculography is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve heart catheterization and 
ventriculography. Our reviewer says that the requested heart catheterization and ventriculography is not 
considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee had 
a radionuclide stress test in 2022, with recommendation for continued medical management without cardiac 
catheterization. The medical records provided do not support the rationale for this invasive imaging study. The 
records do not show an uninterpretable electrocardiogram (ECG) pattern. The guidelines do not support a need 
for cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be 
considered medically appropriate 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 heart catheterization and ventriculography have not been met. Therefore, we 
decided that the Plan does not have to pre-approve heart catheterization and ventriculography.
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 the enrollee is stable and suitable for 
LTACH admission and cannot be adequately cared for in the current condition at a skilled nursing facility. The 
Plan denied your request. The Plan says it is not safe to leave the hospital at this time because the enrollee 
continues to be confused and white blood cells are very high, there is concern for persistent systemic infection. 
The enrollee is receiving the care needed in the current hospital and there is no need to transfer to the LTACH 
at this time. 
 
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 is no documentation provided indicating medical necessity for admission to a 
LTACH, the enrollee is receiving appropriate care at the present acute care hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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 parenteral nutrition supplies billed with codes B4197, 
B4220, and B4224 provided from October 7, 2022, to October 13, 2022. 
 
You asked the Plan to pay for parenteral nutrition supplies. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes B4197, B4220, and B4224 are not supported in the medical record. Specifically, the 
claim image is submitted with frequency code of "8" which is used to "Void/cancel of prior claim". The 
provider would need to resubmit the claim with the correct frequency code. The claim is not payable as billed. 
Based on this information, we decided that Medicare rules for coverage of parenteral nutrition supplies have not been met. Therefore, we decided that the Plan does not have to pay for parenteral nutrition supplies billed 
with codes B4197, B4220, and B4224 provided from October 7, 2022, to October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with a tertiary out-of-network urologist. 
 You asked the Plan to pre-approve a consultation with a tertiary out-of-network urologist. You say that the 
enrollee needs a higher level of care. The Plan denied your request. The Plan says the requested service is not 
urgent or emergent. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for 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 pre-approve a consultation with a tertiary out-of-
network urologist. Our reviewer says that a consultation with a tertiary out-of-network urologist is not 
medically necessary. Our physician reviewer found the Plan is offering adequate care to meet your medical 
needs. The reviewer found that the Plan has shown that this in-network provider meets the Standards of Care 
required for treatment of your condition. The reviewer found the documentation does not indicate anything 
unique about your condition that that would make it medically necessary for you to see the requested tertiary 
out-of-network provider. 
 
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 consultation with a tertiary out-of-network urologist have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a consultation with a tertiary out-of-network 
urologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen system. 
 
You asked the Plan to pre-approve a portable oxygen system. You say that you would like this item for running 
errands outside of the house. The Plan denied your request. The Plan says Medicare covers oxygen equipment 
for use within the home but does not cover oxygen equipment for travel or specific use outside of the home. 
The member was previously provided with a home oxygen system including portable oxygen tanks for oxygen 
needs within the home, and there is no documentation that this equipment is not satisfying the member's 
oxygen needs within the home. 
 
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.  
 
The item at issue in this appeal is for use outside of the home. Although this item 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 pre-approve a portable oxygen system.
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 the enrollee is no longer meeting 
adequate criteria for inpatient hospitalization and do not feel will be able to receive adequate care at a skilled 
nursing facility. The Plan denied your request. The Plan says criteria for admission to the LTACH have not 
been met, the enrollee's medical needs are being met in the current acute setting. With additional time in the 
current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined. 
 
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 transfer to the LTACH is not medically necessary as the enrollee is not yet stable and 
as it would not be clinically advantageous, completion of treatment at the current facility is recommended. 
 
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 (E0652), provided on 
February 23, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item should be covered. The 
Plan denied your request. The Plan says there is no proof of delivery for this service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. There is no proof of 
delivery for this service. 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 pneumatic 
compression device (E0652), provided on February 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Foot surgery for bunionectomy and hammer toe in a 
hospital setting. 
 
You asked the Plan to pre-approve a Foot surgery for bunionectomy and hammer toe in a hospital setting. You 
say that it is medically necessary to have this surgery in a hospital setting. The Plan denied your request. The 
Plan says the surgery has been approved in an ambulatory surgical center setting, it is not medically necessary 
for the surgery to be performed in a hospital. 
 
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 Foot surgery for bunionectomy and 
hammer toe in a hospital setting. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee requires foot surgery for 
bunionectomy and hammer toe and approval has been given for an ambulatory surgery setting. The record 
provided does not document a sufficient medical rationale why the surgery cannot be performed in the 
approved 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 a Foot surgery for bunionectomy and hammer toe in a hospital setting have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Foot surgery for bunionectomy 
and hammer toe in a hospital setting.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cologuard test (81528). 
 You asked the Plan to pre-approve the Cologuard test. You say that the Medicare guidelines recommend colon 
cancer screening start at age 45. Please reconsider approving the Cologuard Test. The Plan denied your request. 
The Plan says the enrollee is 47 years old and does not meet the Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Cologuard test have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Cologuard test (81528).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Baja Wrangler II Scooter (E1399) provided on 
September 23, 2022. 
 
You asked the Plan to reimburse you for the scooter. You say that your primary doctor prescribed this scooter. 
You say that the clearance on a normal mobility scooter is not adequate for your neighborhood. You also say 
that you are afraid that without this scooter, you will become more homebound. The Plan denied your request. 
The Plan says the requested group 2 POV is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that group 2 power operated vehicles (POVs) have 
added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided it will be 
denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the scooter have not been met. Therefore, we decided that the Plan does not have to reimburse you 
for the Baja Wrangler II Scooter (E1399) provided on September 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs these supplies. The 
Plan denied your request. The Plan says the requested supplies are not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 1, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 1, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve molecular pathology testing. 
 
You asked the Plan to pre-approve molecular pathology testing. You say that molecular pathology testing is 
medically necessary. The Plan denied your request. The Plan says molecular pathology testing does not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve molecular pathology testing. Our 
reviewer says that the requested molecular pathology testing is not medically necessary. Our physician 
reviewer found that the use of next-generation sequencing (NGS) panel testing as a means to select anti-cancer therapy in advanced cancer remains an area of active research with ongoing studies of TPUR and MATCH. 
There is no specific clinical rationale for the requested laboratory test. The review has determined that the 
requested unlisted molecular pathology procedure, lab test done to look for errors in the genes does not meet 
the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of molecular pathology testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve molecular pathology testing.
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. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
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 is no documentation provided indicating medical necessity for admission to a 
LTACH. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76856 billed for date of service November 3, 
2022. 
 You asked the Plan to pay for procedure code 76856. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 76856 is bundled into payment for code 
93975. 
 
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 76856 
is a column II code to column I code 93975. 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 76856 billed for date of service November 3, 
2022.