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

 
We decided that the Plan does not have to pre-approve an office visit (99204) with a tertiary general surgeon to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to continue your care with the 
requested provider. You were sent to a different provider which is a dermatologist, and you need a melanoma 
surgeon for a biopsy. The Plan denied your request. The Plan says your notes do not show that you need 
tertiary level care. It was determined that there was no medical necessity for this request. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 an office visit. Our reviewer says that the service is not medically 
necessary. Our physician reviewer found you have a history of melanoma of the left great toe previously 
treated by an OON provider at UCI in 2018. You were last seen for follow up care with that provider on 
August 31, 2021. A new lesion was noted on the right mid back. You would like to return to the OON provider 
for the treatment of a new lesion. Per the coverage criteria, tertiary level service is medically necessary when 
care is needed that the Plan's doctors are not able to provide, when care is needed from a group of doctors and 
staff who work together as a team or when care is needed that can only be safely done at a tertiary level center. 
In this case, your condition can be taken care of within the Plan. The review has determined that the 
items/services at issue in this case are not medically reasonable and necessary. You do not need tertiary care by 
a general surgeon. You can be treated by a community in network provider instead. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office visit have not been met.  
 
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 an office visit. Therefore, we decided that the Plan 
does not have to pre-approve an office visit (99204) with a tertiary general surgeon to be provided by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64494 provided on August 23, 2022. 
 
You asked the Plan to pay for procedure code 64494. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 64494 is not supported in the medical record. Specifically, this code has a payment 
indicator of "N". No separate payment can be made for this code as it is considered a packaged service. Based 
on this information, we decided that Medicare rules for coverage of procedure code 64494 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 64494 provided on August 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cxbladder Detect test (0012M) provided July 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the denial of coverage for 
the Cxbladder Detect test for the enrollee. The Plan denied your request. The Plan says Cxbladder tests are 
considered experimental/ investigational. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for Cxbladder Detect test (0012M) provided July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided on September 11, 
2022. 
 
You asked the Plan to pay for an ankle-foot orthosis. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollee's medical record adequately supports the medical necessity for the item. 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The medical records provided do not discuss the item at issue. 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 an ankle-foot orthosis (L1971) provided on September 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81450). 
 You asked the Plan to pre-approve genetic testing. You say that the requested services are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the request 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 genetic testing. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested extensive testing is not indicated for making the diagnosis of suspected 
polycythemia vera. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81450).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter and lift chair.  
You asked the Plan to pre-approve a power scooter and lift chair. You say that you get easily disoriented and 
need assistance walking. You also say that you suffer from chronic pain and have permanent damage 
throughout your body. The Plan denied your request. The Plan says the requested items are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that durable medical equipment is covered when certain 
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 a lift chair. Our reviewer says that the 
requested lift chair is not medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee is able to stand and walk. The documentation also shows that the requested lift chair 
is for the purpose of sleeping on an incline. Therefore, the reviewer found that the requested lift chair 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 a power scooter and lift chair have not been met. Specifically, the file does not 
include a physician order for a power scooter. Additionally, the file shows that you can stand and walk and thus 
do not meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve a power 
scooter and lift chair.
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 services are medically necessary for the enrollee 
to receive the needed care. The Plan denied your request. The Plan says the services the enrollee needs can be 
provided safely in another setting such as a skilled nursing facility, home with home health services or home 
with outpatient therapy. 
 
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 enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that they 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF. The enrollee can receive further services at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a discharge day management visit provided on February 28, 
2022. 
 
You asked the Plan to pay for discharge day visit. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the Plan is not responsible for payment of this claim because the enrollee was in a 
hospice program on this date.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a discharge day management visit provided on February 28, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 25, 2022, billed with 
codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 81314, 81334, 81345, 
81272 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 25, 2022, billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 
81209, 81314, 81334, 81345, 81272 and 81479.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate 
its safety and efficacy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (Life2000) (E0466). 
 
You asked the Plan to pre-approve Life2000. You say that the requested ventilator was prescribed to help 
manage the enrollee's pulmonary exacerbations at home. The Plan denied your request. The Plan says the 
requested ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 Life2000. Our reviewer says that the requested Life2000 is not medically necessary. Our physician reviewer found the provided documentation 
indicates the enrollee has severe combined obstructive and restrictive lung disease, with chronic obstructive 
pulmonary disease (COPD) and kyphoscoliosis related to past polio. The reviewer found there is no evidence 
of chronic carbon dioxide (CO2) retention. The Life2000 device is not a true ventilator, because it is not 
capable of providing full ventilatory support. The reviewer found that its primary intended use is during 
activity, and not to treat chronic CO2 retention during sleep. The reviewer found there is inadequate evidence 
of the safety and effectiveness of this device in the treatment of COPD or restrictive lung disease. Therefore, 
the reviewer found that the requested Life2000 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 Life2000 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a home ventilator (Life2000) (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator (E0747). 
 
You asked the Plan to pre-approve an electrical bone growth stimulator. You say that this item is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not have evidence of nonunion as 
defined by absence of healing demonstrated on two radiographs separated by at least 90 days. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 an electrical bone growth stimulator. 
Our reviewer says that the criteria are not met for the electrical bone growth stimulator. Our physician reviewer 
found the diagnosis of fracture nonunion has not been clearly established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical bone growth stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an osteogenesis stimulator (E0747).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
September 9, 2022. 
 
You asked the Plan to pay for the CGM supplies. The Plan denied your request. The Plan says the billed 
service cannot be verified. 
 
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. Medicare rules also say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The submitted 
documentation does not contain a proof of delivery for the date of service in question. The packing slip is dated 
August 29, 2022, and the delivery ticket is dated September 1, 2022. As such, there is insufficient information 
in the record to determine if Medicare rules for coverage of the CGM supplies have been met. 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 continuous glucose monitor (CGM) supplies provided on 
September 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
  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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 30, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 30, 2022.
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. You say that you are currently at home and require immediate 
inpatient observation oversight services in excess of what your family can provide at home. The Plan denied 
your request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
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 your medical problems are stable and 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 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.