Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Gauze (A6219) and Hydrogel dressing (A6248) provided 
on December 1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for codes A6219 and A6248. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services provided were neither 
emergent nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 requested 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 Gauze (A6219) and Hydrogel dressing 
(A6248) provided on December 1, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) home visits. 
 
You asked the Plan to pre-approve the PT visits. You say that the enrollee has lost her strength and confidence, 
and lives alone. You also say that you are hoping to build confidence, strength in the enrollee's legs, and 
improve the enrollee's balance. The Plan denied your request. The Plan says Medicare criteria for home 
physical therapy services are not met and medical necessity is not established. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 PT visits. Our reviewer says that 
home health PT is not medically necessary or reasonable. Our physician reviewer found the enrollee does not 
have documented, ongoing, skilled PT needs. 
 
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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy (PT) home visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on September 29, 2021. 
 
You asked the Plan to pay for the diabetic supplies. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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. 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 diabetic supplies provided on September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a primary closure of a sinus perforation (D7261). 
 
You asked the Plan to pre-approve a primary closure of a sinus perforation. You say that the requested service 
is medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered 
benefit. 
 
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 a 
primary closure of a sinus perforation (D7261).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150) provided March 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the record does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 
(87150) provided March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 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 was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided June 11, 2021. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim is a duplicate. 
 
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 code 99213 is not supported in the medical record. Specifically code 99213 was  
already billed under referring claim 820211810514557 for the same date of service and same provider. This 
service is considered inclusive to another procedure billed on the same day (11420) and is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the office visit have not 
been met. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided June 
11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomographic angiography (CTA) scan of the 
chest (71275) 
 
You asked the Plan to pre-approve CTA scan of the chest. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested imaging service is not 
medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CTA scan of the chest. Our reviewer 
says that this is medically reasonable and necessary. Our physician reviewer found the record indicates that the 
enrollee has a history of pulmonary embolism. The enrollee has been on anticoagulation and the requested 
service is to determine the need for continued anticoagulation. The record provided does not demonstrate the 
medical necessity, as defined by Medicare rules, of the requested service for the enrollee's clinical condition. 
The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of 
the requested service. The elements of the coverage criteria are not satisfied.  The requested service cannot be 
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 CTA scan of the chest have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomographic angiography (CTA) 
scan of the chest (71275)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) with an oral 
surgeon. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation with an oral surgeon. You say that the 
requested service is medically necessary. The Plan denied your request. The Plan says the service at issue is not 
covered unless it is performed by a participating general dentist. Dental services performed by an oral surgeon 
are not covered. 
 
  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.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation with an oral surgeon have not been met. Specifically, the service 
at issue is not covered unless it is performed by a participating general dentist. Therefore, we decided that the 
Plan does not have to pre-approve a comprehensive oral evaluation (D0150) with an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 26, 2020. 
 You asked the Plan to pay for the laboratory services. You say that the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on October 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed more than 4 
months of conservative approaches. The Plan denied your request. The Plan says research has not found it to be 
helpful for the enrollee's condition. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for spinal stenosis, lumbar region with neurogenic 
claudication. He presented with pain located in the right-sided low back and hip pain. The pain radiates down 
the right leg to the thigh. An exam reveals paraspinal tenderness. There is limited range of motion. Current 
evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression 
device procedure over the lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed 
outcome studies to support the use of this device for this enrollees medical condition. There is imaging 
evidence of mild apex right lumbar curvature of the lumbar spine, with no documentation of the Cobb angle.  There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in 
this enrollee. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the request interspinous stabilization 
device at L4-L5 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of wound vacuum services. 
 
You asked the Plan to pre-approve the continued use of wound vacuum services. You say that this therapy has 
been successful and should be continued with the enrollee's treatment. The Plan denied your request. The Plan 
says the duration of use of this equipment cannot be more than 4 months. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of negative pressure wound therapy 
services will end when 4 months have elapsed using a negative pressure wound therapy pump in the treatment 
of the most recent wound. 
 
We looked at the file and Medicare rules. In this case, the 4 month period of treatment has elapsed. Based on 
this information, we decided that Medicare rules for coverage of the continued use of wound vacuum services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the continued use of 
wound vacuum services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (98940) provided on August 6, 
2021, through September 15, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration because 
chiropractic services should be covered. The Plan denied your request. The Plan says this provider is on the 
Office of the Inspector General's exclusion list. 
 
The Plan must follow Medicare rules. Medicare rules say that the Secretary shall exclude any individual or 
entity which has been suspended or excluded from participation, or otherwise sanctioned, under any Federal 
program for reasons bearing on the individuals or entitys professional competence, professional performance, 
or financial integrity from participation in any Federal health care program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chiropractic services have not been met. Therefore, we decided that the Plan does not have to 
pay for the chiropractic services (98940) provided on August 6, 2021, through September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a TenJet tenotomy procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this procedure has had proven results on 82% of patients with a full recovery. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is an experimental and investigational procedure. Therefore, the request is considered 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a TenJet tenotomy procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82607, 82728, 82746, 83540, 83550) provided 
July 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the lab services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of End-Stage renal disease (ESRD) are included in the ESRD PPS as Part B services and are 
not paid separately as of January 1, 2011. 
 
We looked at the file and Medicare rules. This service was included in payment for the ESRD services and is 
not separately payable. 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 (82607, 
82728, 82746, 83540, 83550) provided July 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator (E0748). 
 
You asked the Plan to pre-approve a bone growth stimulator. You say that this device is medically reasonable 
and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a bone growth stimulator will be covered when 
there is a failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the 
last surgery. 
 
We looked at the file and Medicare rules. In this case, the enrollee received surgery in February 2022. Nine 
months have not elapsed since this last surgery. Based on this information, we decided that Medicare rules for 
coverage of a bone growth stimulator have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a bone growth stimulator (E0748).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is 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 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. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0241U and 87651) provided on 
August 16, 2021. 
 
You asked the Plan to pay for the laboratory services (0241U and 87651). You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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. Furthermore, the file 
does not contain documentation of an established relationship between the enrollee and the ordering provider. 
Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (0241U and 
87651) provided on August 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on August 12, 2021.