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

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve) (64555) and insertion or replacement of peripheral or 
gastric neurostimulator pulse generator or receiver, direct or inductive coupling (64590). 
 
You asked the Plan to pre-approve Percutaneous Neuromodulation Therapy (or PNT) using a ReActiv8 device. 
You say that the requested procedures are medically necessary. The Plan denied your request. The Plan says 
the requested procedure does not meet criteria. 
 
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 Percutaneous Neuromodulation 
Therapy (or PNT) using a ReActiv8 device. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is 
considered experimental/ investigational. There are not enough studies to show this nerve procedure improves 
the health of patients with the enrollee's problem, show that this nerve procedure is better than regular 
treatment, or show that this nerve procedure will help in the enrollee's 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 Percutaneous Neuromodulation Therapy (or PNT) using a ReActiv8 device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous 
implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555) and insertion 
or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling 
(64590).
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely in other settings. 
 
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. There 
is ongoing concern with this patient's anemia and myelodysplastic syndrome that indicates further care in the 
short term acute care hospital appears to be most appropriate. The patient does require physical therapy and occupational therapy services, but the medical records provided do not clarify why the patient requires an 
intensive inpatient rehabilitation therapy program. Provided records do not explain why the intensive inpatient 
rehabilitation therapy program is necessary and why therapy at a lower level of care such as in a skilled nursing 
facility is not appropriate for the patient. There is not a reasonable expectation that this patient will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for IRF 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. This procedure improves the quality of life of patients suffering from 
vertebrogenic low back pain. Given the recently submitted history, physical examination and radiologic 
finding, the Intracept procedure is medically necessary and supported by strong science. The Plan denied your 
request. The Plan says the request is not medically necessary because there is little evidence in the medical 
literature to suggest that this is an appropriate procedure for the enrollee's back pain. 
 
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 procedure. 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 considered experimental and investigational. More research 
is needed in order to approve this procedure. 
 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 procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 23, 
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 March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 1, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided January 1, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment. You say that you had a medical issue and 
were not able to get prior authorization. The Plan denied your request. The Plan says this service is not covered 
because the provider is out-of-network. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 1, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided January 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDX-SCC test provided on April 5, 2022. 
 
You asked the Plan to pay for the DecisionDX-SCC test. You say that the DecisionDX-SCC test provided on 
April 5, 2022, was medically necessary. The Plan denied your request. The Plan says the DecisionDX-SCC test 
provided on April 5, 2022, was 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 pay for the DecisionDX-SCC test. Our reviewer 
says that the DecisionDX-SCC test provided on April 5, 2022, was not medically necessary. Our physician 
reviewer found the National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2022 Squamous 
Cell Skin Cancer does not discuss the use of molecular studies for risk stratifying cutaneous squamous cell 
cancers. Some data exists for using molecular studies for patients in the higher risk NCCN category but based on NCCN Criteria this enrollee is low risk. The service is not reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DecisionDX-SCC test have not been met. Therefore, we decided that the 
Plan does not have to pay for the DecisionDX-SCC test provided on April 5, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the DecisionDX-SCC testing provided on March 22, 2022. 
 
You asked the Plan to pay for the DecisionDX-SCC testing. You say that the DecisionDX-SCC testing 
provided on March 22, 2022, was medically necessary. The Plan denied your request. The Plan says that the 
DecisionDX-SCC testing provided on March 22, 2022, was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the DecisionDX-SCC testing. Our reviewer 
says that the DecisionDX-SCC testing provided on March 22, 2022, was medically necessary. Our physician 
reviewer found the National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2022 Squamous 
Cell Skin Cancer does not mention the use of molecular profiling. Based on NCCN Guidelines this enrollee is 
very high risk. Several studies have evaluated tumor markers in Cutaneous Squamous Cell Cancer (cSCC) and 
identified associations with aggressive tumors. As the composite definition of high-risk cSCC remains unclear, 
the identification of reliable biomarkers is particularly promising in aiding the recognition of patients at risk for 
poor outcomes and guiding clinical disease management. Several studies have shown that Gene Expression 
Profiling (GEP) can be an additional tool in determining treatment decision making in patients with high-risk 
tumors such as this one. The service was reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DecisionDX-SCC testing have been met. Therefore, we decided that the 
Plan has to pay for the DecisionDX-SCC testing provided on March 22, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99204, 99202) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that it is recommended the enrollee be referred to a 
higher level of care with the requested provider. The Plan denied your request. The Plan says the enrollee must 
use network providers to get her medical care and services.  The Plan has confirmed there is no network 
deficiency for the enrollees service area for the requested service. There are in-network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (99204, 99202) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walk-in, portable, whirlpool tub provided on August 7, 
2020. 
 
You asked the Plan to pay for a walk-in, portable, whirlpool tub. You say that you cannot deny my claim 
because of the time that you put the claim in. You also say that you put your request in before you received the 
walk-in bath. The Plan denied your request. The Plan says the claim was not received within the allowed 12 
months from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for a walk-in, portable, whirlpool tub was not filed until April 25, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for a walk-in, portable, whirlpool tub provided on 
August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stem cell injections. 
 
You asked the Plan to pre-approve the requested services. You say that you need to rehab the bone. The Plan 
denied your request. The Plan says there is insufficient evidence to support its efficacy. 
 
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 you have a medical history of pain due to osteoarthritis of the left hip. Based on the 
medical records provided, review of current treatment guidelines, and the Medicare-approved major drug 
compendia, there is no documentation that the stem cell injections at issue in this case meet Medicare criteria 
for medically reasonable and necessary, safe and effective. Stem cell injections for hip osteoarthritis have not 
been shown to be safe and effective in high quality clinical studies to meet Medicare criteria for coverage. 
 
 
 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 stem cell injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 system. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 system. 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 system.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 30, 2022, 
to February 4, 2022. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
had no skilled therapy or skilled nursing service needs, and did not meet the Medicare coverage guidelines for a 
continued stay in a SNF. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 30, 2022, to February 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure, Caris Molecular 
Intelligence(r) tumor testing (81479) provided January 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this test was ordered by an in-network 
physician who determined the results of these services are medically necessary to provide the best care for the 
enrollee. The Plan denied your request. The Plan says this test is experimental/investigational and is a non-
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
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. Therefore, we decided that the Plan does not have to pay for the unlisted molecular pathology procedure, Caris Molecular Intelligence(r) tumor testing (81479) provided 
January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
February 2, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD 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. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at home coronavirus (COVID-19) test provided on 
December 20, 2021. 
 
You asked the Plan to pay for at home coronavirus (COVID-19) test. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says per the Centers for Medicare and Medicaid 
Services (CMS) guidelines, Medicare coverage and payment began on April 4, 2022. The Plan also says that 
the members 2022 Evidence of Coverage says if the member gets services that are excluded (not covered), the 
member must pay for the services themselves. The Plan also says that they will not pay for excluded medical 
services.  
The Plan must follow Medicare rules. Medicare rules say that a new initiative on April 4, 2022, that will cover 
up to eight over-the-counter COVID-19 tests each calendar month, at no cost to you.  
 
We looked at the file and Medicare rules. The at home coronavirus (COVID-19) test you purchased was on 
December 20, 2021, which was before the date that Medicare rules issues the new initiative, which was April 4, 
2022. Based on this information, we decided that Medicare rules for coverage of at home coronavirus (COVID-
19) test have not been met. Therefore, we decided that the Plan does not have to pay for at home coronavirus 
(COVID-19) test provided on December 20, 2021.