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

 
We decided that the Plan does not have to pay for presumptive drug testing (80307) billed for date of service 
April 12, 2022. 
 
You asked the Plan to pay for presumptive drug testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this service cannot be paid under the Physician Fee Schedule and may 
only be paid under the Clinical Laboratory Fee Schedule to the performing laboratory. 
 
The Plan must follow Medicare rules. Medicare rules say that if a clinical laboratory test is subject to the 
laboratory fee schedule, A/B MACs (B) must pay only the person or entity that performed or supervised the 
performance of the test.  
 
We looked at the file and Medicare rules. The record shows that the billing provider in this case is the ordering 
physician rather than the laboratory who performed these services. Code 80307 is excluded from payment 
under the Physician Fee Schedule and is not in the statutory definition of physician services. This service is 
only payable under the Laboratory Fee Schedule to the person or entity that performed or supervised this test. 
Based on this information, we decided that Medicare rules for coverage of presumptive drug testing have not been met. Therefore, we decided that the Plan does not have to pay for presumptive drug testing (80307) billed 
for date of service April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that a more complex drug screening was provided. The 
Plan denied your request. The Plan says the code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by code 83789 is considered 
specimen validity testing which 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 the lab services provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MBBs are covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has osteoarthritis and 
moderate to severe low back pain related to lumbar spondylosis without radiculopathy. He has tried physical 
therapy, medications, rest, and bracing. He has not had any prior facet injections; therefore, the criteria for 
coverage of MBBs are not met. The MBBs are not reasonable or medically necessary at this time.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve medial branch blocks (MBBs).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare due to insufficient evidence of 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion device at the L3-
4 level, in this case, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genicular nerve radiofrequency ablation provided to the 
enrollee on June 21, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not billed with a covered diagnosis. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered an experimental procedure which is the subject of ongoing clinical 
trials. Therefore, the procedure was 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for genicular nerve radiofrequency ablation provided to the enrollee on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve autologous serum tears. 
 
You asked the Plan to pre-approve autologous serum tears. You say that this is the only product that works for 
you. You also say that you cannot use any products with preservatives. The Plan denied your request. The Plan 
says there is insufficient evidence to show that the requested serum tears is likely to improve your health 
outcome as much as, or more than, established alternative standard therapies. 
 
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 autologous serum tears. Our reviewer 
says that the requested autologous serum tears are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the current medical literature does not support the autologous serum tears 
as improving net health outcomes compared to standard available treatments. Therefore, the reviewer found 
that the requested autologous serum tears are 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 autologous serum tears have not been met. Therefore, we decided that the Plan 
does not have to pre-approve autologous serum tears.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks (64454 x 2) for the left knee. 
 
You asked the Plan to pre-approve the injections. You say that you are currently in pain. You also say that you 
need this to be figured out before your scheduled injection on October 28, 2022. The Plan denied your request. 
The Plan says the requested injections are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that 
the requested injections are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation indicates that the enrollee has had knee pan for 90 days. The 
reviewer found that there is no indication of the specific treatments that have been tried. The reviewer found 
there is no evidence of exam or x-ray of the knee. The reviewer also found that genicular nerve blocks and 
genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic 
knee pain. Therefore, the requested injections are not medically 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve blocks (64454 x 2) for the left knee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a Vertiflex device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Vertiflex device is experimental. 
 
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 insertion of a Vertiflex device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve epidural steroid injection. You say that the enrollee is in deep pain. The Plan 
denied your request. The Plan says the enrollee has not had at least 50% pain relief and improved function for 3 
months following the previous injection.  
The Plan follows Medicare rules. Medicare rules state that repeat epidural steroid injections are only covered 
when the record documents at least 50% sustained improvement in pain relief and/or function for at least 3 
months following the initial injection. 
 
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 epidural steroid injection. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested epidural. Our physician reviewer 
found there is no role for a series of epidural steroid injections. Medicare rules require 50% pain relief for 3 
months before another injection can be considered. That time period has not passed, so this is not medically 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Human Papillomavirus (HPV) testing (87624) provided on 
May 12, 2022. 
 You asked the Plan to pay for HPV testing. You say that this diagnostic test was medically necessary as the 
enrollee has had previous abnormal results. The Plan denied your request. The Plan says this screening was not 
medically necessary and was not billed with an appropriate associated diagnosis. 
 
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 HPV testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this test was not medically necessary as the enrollee in this case was not asymptomatic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HPV testing have not been met. Therefore, we decided that the Plan does not 
have to pay for Human Papillomavirus (HPV) testing (87624) provided on May 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression device. 
 
You asked the Plan to pre-approve pneumatic compression device. 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 follows Medicare rules. Medicare rules say that a pneumatic compression device (PCD) coded as 
E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when 
specific criteria are met. 
 
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 pneumatic compression device. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
documentation does not support that the beneficiary has failed at least 4 weeks of conservative care with a 
basic lymphedema pump. Additionally, the documentation does not support that the member has physical 
findings consisting of truncal, abdominal or chest edema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pneumatic compression device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pneumatic compression device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken with two exceptions. The two exceptions are for enrollees who are 
registered hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would 
be reported regardless of where the face-to-face service takes place. 
 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 office setting POS 
code. The records do not support that the sample was taken in an office setting. The record shows that the 
specimen was obtained in an on-campus outpatient hospital setting. Therefore, we decided that the Plan does 
not have to pay for lab services provided on March 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that the requested Orthovisc is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Orthovisc.  
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Orthovisc. Our reviewer says that the 
enrollee does not meet criteria for the requested Orthovisc. Our physician reviewer found the review indicates 
that the enrollee is with right knee pain due to osteoarthritis. He has tried and failed physical therapy and 
NSAIDS.  He has not had previous steroid injections. The enrollee's provider requested viscosupplementation 
therapy with Orthovisc. According to the coverage criteria, viscosupplementation therapy is indicated when the 
patient has failed to respond to aspiration of the knee when effusion is present and intra-articular corticosteroid 
injection therapy when inflammation is a significant component of the patients symptoms and intra-articular 
corticosteroids are not contraindicated. In this case, the enrollee has not had a steroid injection. The review has 
determined that the enrollee does not meet the above LCD criteria for the requested Orthovisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMs device. 
 
You asked the Plan to pre-approve the CardioMEMs device. You say that the records provided support the 
need for the requested device. You say that the CardioMEMs is medically necessary for the enrollee's specific 
clinical need. The Plan denied your request. The Plan says the clinical value and effectiveness of the 
CardioMEMs device has not been demonstrated in the peer-reviewed literature. 
 
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 CardioMEMs device. Our reviewer 
says that the CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMs in patient management. As a result, at this time the 
CardioMEMs system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the CardioMEMs device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about your condition you do not meet all the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
cholangitis, jaundice and pancreatitis. Medical problems are stable.  There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided a in a different level of 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 IRF admission and services.