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

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service August 17, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. The Plan denied your request. The Plan says this code 
is included in the facility payment and is 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. 
 
Per the Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. No TC 
billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, 
generally through the Hospital Fee Schedule payment rate. No payment is recognized for CPT code 85060 
furnished to hospital outpatients or non-hospital patients. Based on this information, we decided that Medicare 
rules for coverage of procedure code 85060 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code(s) 85060 billed for date of service August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat facet joint injection (64493). 
 
You asked the Plan to pre-approve a repeat injection. You say that the injection is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet all the criteria. 
 
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 repeat injection. Our reviewer says 
that the requested repeat injection is not medically necessary. Our physician reviewer found the provided 
documentation does not support that the prior radiofrequency ablation (RFA) was successful. The reviewer 
found that it is not appropriate to repeat facet blocks at the same level. Therefore, the reviewer found that the requested injection is 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 a repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat facet joint injection (64493).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit for assessment and 
management of a patient provided to the enrollee on April 13, 2022. 
 
You asked the Plan to pay for the services. You say that the added modifier is correct for opioid dependency. 
The Plan denied your request. The Plan says the code and modifier combination was not found to be 
appropriate. 
 
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 G0463 is "Hospital outpatient clinic visit for assessment 
and management of a patient." 
 
The denied was billed with modifier HF, which is inappropriate. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for a hospital outpatient clinic visit for assessment and management of a patient provided to the 
enrollee on April 13, 2022.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have 
not been met. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. The Plan has approved ongoing care in the current acute care 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 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 pre-approve an automatic pill dispenser (E1399). 
 
You asked the Plan to pre-approve a pill dispenser. You say that you take 8 different medications every day 
and it is becoming difficult to manage. The pill dispenser keeps you organized. The Plan denied your request. 
The Plan says an automatic pill dispenser is not considered to be primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an automatic pill dispenser (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytogenetics and molecular cytogenetics, interpretation and 
report (88291) provided on May 13, 2022. 
 
You asked the Plan to pay for the cytogenetics testing. You say that this service is medically necessary. The 
Plan denied your request. The Plan says code 88291 is not a Medicare benefit for the diagnoses listed on the 
claim. 
 
The Plan follows Medicare rules. Medicare rules say that cytogenetics testing is covered for the indications 
listed in the Medicare Rules section of this letter.  
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 the cytogenetics testing. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that the enrollee has mantle cell 
lymphoma and is on therapy with bendamustine regimen. This is not a covered diagnosis for code 88291. Thus, 
the cytogenetics testing was not medically reasonable and necessary in this case. 
 
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 cytogenetics testing have not been met. Therefore, we decided that the Plan 
does not have to pay for cytogenetics and molecular cytogenetics, interpretation and report (88291) provided 
on May 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records show that this procedure has already been in the left leg and the requested 
greater saphenous vein. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that a venous duplex of the bilateral lower extremities on 12/23/22 demonstrated superficial venous 
thrombosis involving the left greater saphenous vein. The available documentation is insufficient to support 
that the coverage criteria for endovenous laser ablation therapy have been met in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation therapy of incompetent vein.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen accessory, battery pack/cartridge for portable 
concentrator, any type, replacement only, each (E1356). 
 
You asked the Plan to pre-approve replacement battery. You say that the portable oxygen concentrator only 
provides up to 4 hours of battery life and you would like to have an extra batter to be able to be more social 
with relatives for the upcoming holidays. The Plan denied your request. The Plan says Medicare does not cover 
an extra set of batteries, or a double battery. 
 
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 replacement battery have not been met. Therefore, we decided that the Plan does not have to pre-
approve oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each 
(E1356).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation. 
 
We looked at the file and Medicare rules. Specifically, the record shows that the claim was billed with 
diagnosis code Z99.3. This code has a code first note, which means it is a manifestation code and must be 
sequenced after an etiology code. Based on this information, we decided that Medicare rules for coverage of 
the services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance 
services provided on July 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Emgality. 
 
You asked the Plan to pre-approve Emgality. The Plan denied your request. The Plan says the requested drug 
does not fall under Part B coverage. The Plan says that they do not administer pharmacy benefits for the 
enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Emgality.  
 
Benefits for Emgality may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 17, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One (J7325). 
 
You asked the Plan to pre-approve Synvisc-One. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Euflexxa, Supartz FX, Durolane, and Gelsyn-3. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc-One. Our reviewer says that 
the step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed at least two of the preferred drugs. The reviewer found that the 
documentation does not indicate contraindications or reasons these medications were not considered or that the 
plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NeuroTrax testing (96132, 96133, 96138, 96139). 
 
You asked the Plan to pre-approve NeuroTrax testing. You say that the enrollee suffers from mild cognitive 
impairment. You say that NeuroTrax testing will help define how each of the enrollee's cognitive domains are 
affected and can be followed over time. The Plan denied your request. The Plan says the requested testing is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing does not rely on self-
report questionnaires when questions of how brain damage or degenerative disease processes may be affecting 
emotional expression or how significant emotional distress or mood impairment might be affecting cognitive 
function arise. 
 
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 NeuroTrax testing. Our reviewer says 
that the requested NeuroTrax testing is not medically necessary. Our physician reviewer found that the 
requested testing is automated. The reviewer also found that automated testing is not considered reasonable or 
medically necessary for this enrollee with known memory deficit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of NeuroTrax testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve NeuroTrax testing (96132, 96133, 96138, 96139).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this procedure fills a gap for patients that do not 
receive adequate relief from traditional conservative methods and do not have instability to indicate that fusion 
is appropriate. The Plan denied your request. The Plan says studies have not proven that this is 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laser cataract surgery. 
 
You asked the Plan to pre-approve laser cataract surgery. The Plan denied your request. The Plan says this 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 laser cataract surgery. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that the enrollee has cataracts. The record provided is 
insufficient to establish the medical necessity of the requested procedure compared to standard available 
therapies. The record does not establish the medical necessity and reasonableness, as defined by Medicare 
rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laser cataract surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve laser cataract surgery.
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 IRF care will help your return to your prior level of 
independence. The Plan denied your request. The Plan says you do not need an IRF 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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Chimeric Antigen Receptor (CAR) Therapy. 
 
You asked the Plan to pre-approve CAR Therapy. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 CAR Therapy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found CAR Therapy is not indicated in central 
nervous system (cns) lymphoma. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CAR Therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Chimeric Antigen Receptor (CAR) Therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bioimpedance spectroscopy (93702). 
 
You asked the Plan to pre-approve the diagnostic procedure. You say that you are appealing the use of 
Bioimpedance spectroscopy that was medically necessary for the enrollee. The Plan denied your request. The 
Plan says this service is experimental and investigational and there are not enough studies to show that 
Bioimpedance spectroscopy will help in the enrollee's care. 
 
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 diagnostic procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Bioimpedance spectroscopy (93702).