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

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are appealing for wrongful denial 
for intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. The 
Plan denied your request. The Plan says medical studies have not proven this service/item is helpful for the 
treatment of the enrollee's health problem. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found one double-blind randomized study has shown that improvement with the Intracept 
procedure was not clinically significant when compared with a sham procedure. Additional studies suggest that the Intracept procedure may be more effective for low back pain than conservative treatment. Limitations of the 
published medical literature include a limited number of studies, industry funding of the studies, and a high risk 
of bias from lack of controls. Additional study is needed to validate any benefit of the procedure, and to 
compare it to other interventions. Current medical literature indicates that the Intracept procedure is 
investigational at this time. In addition, the provided records in this case document other possible sources of the 
enrollees back pain (besides vertebrogenic pain for which the Intracept procedure is indicated) including facet 
arthropathy and foraminal stenosis. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Via Disc NP Allograft procedure. 
 
You asked the Plan to pre-approve the procedure. 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that shows this 
procedure to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
demonstrate this procedure has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested VIA Disc NP allograft procedure 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Via Disc NP Allograft procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the portable oxygen concentrator (E1390) 
miscellaneous durable medical equipment (E1399) purchased October 19, 2022. 
 
You asked the Plan to reimburse you for the oxygen equipment. You say that you need oxygen per the form 
provided by your doctor. You travel in your motorhome, so you needed the portable concentrator. The Plan 
denied your request. The Plan says the equipment was purchased from a provider who is not certified with 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen 
concentrator (E1390) miscellaneous durable medical equipment (E1399) purchased October 19, 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 14, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim should be paid. 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 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genicular nerve block provided on October 31, 2022. 
 
You asked the Plan to pay for the genicular nerve block. You say that the genicular nerve block was medically 
necessary. The Plan denied your request. The Plan says genicular nerve blocks are considered investigational 
and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. 
 
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 genicular nerve block. Our reviewer says 
that the requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this procedure is considered experimental/investigational at this time and is the 
subject of ongoing clinical trials. Therefore, the request is deemed not medically reasonable and 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pay for a genicular nerve block provided on October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service October 26, 
2022.  
You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. 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. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 3 for CPT code 99153. This means there 
is only a technical component for the CPT code. In this case, an appropriate modifier to indicate the technical 
component has not been billed with CPT code 99153. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99153 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99153 billed for date of service October 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 20, 2022, billed with 
codes 87481 (59), 87640 (59), 87641 (59), 87491 (59), 87496 (59), 87500 (59), 87511 (59), 87529 (59), 87532 
(59), 87563 (59), 87591 (59), 87651 (59), 87653 (59), 87661 (59), and 87798 (59). 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 
June 20, 2022, billed with codes 87481 (59), 87640 (59), 87641 (59), 87491 (59), 87496 (59), 87500 (59), 
87511 (59), 87529 (59), 87532 (59), 87563 (59), 87591 (59), 87651 (59), 87653 (59), 87661 (59), and 87798 
(59).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 You asked the Plan to pre-approve the home health skilled nursing services. The Plan denied your request. The 
Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health skilled nursing 
services. Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found the enrollee does not have documented skilled nursing needs. The requested home health 
skilled nursing services are not medically necessary or reasonable. 
 
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 home health skilled nursing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (30140) provided on August 25, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not supported. 
 
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 30140 is submucous resection inferior turbinate, partial 
or complete, any method. 
 
We asked our coder 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 surgical services. Our reviewer says that the records do 
not support the billed services. Our reviewer found the operative report provided for review did not sufficiently describe the billed procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (30140) provided on August 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on July 25, 2022, through 
August 23, 2022. 
 You asked the Plan to pay for the outpatient services. You say that you should be reimbursed for the services. 
The Plan denied your request. The Plan says no proof of payment was submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee. The rules also say a plan must disclose to its enrollees in clear, accurate terms all cost sharing 
information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that 
you must pay a $150 copayment for each visit to a hospital outpatient surgical department and a $5 copayment 
for each specialist office visit. The Plan contract also states that to receive reimbursement for services, 
enrollees must submit documentation of the payment that was made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Specifically, the record indicates that the Plan has paid 
the Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed 
amount as payment in full. In this case, the Plan is not responsible for paying the balance that remains after the 
Medicare allowed payment. You also have been asked to pay a $150 copayment for abdominal surgery and a 
$5 copayment for an office visit. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Reimbursement was denied for special services and medical supplies because the submitted 
documentation did not include documentation that payment was made for these items and services. Therefore, 
we decided that the Plan does not have to pay for the outpatient services provided on July 25, 2022, through 
August 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided January 2, 2022, to 
January 3, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you request review of the enclosed 
medical records and overturn the denial based on the medical necessity of the services provided. The Plan denied your request. The Plan says the records does not support that criterion were met for inpatient 
hospitalization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency department with a complaint of near 
syncope. The enrollee has a history of dementia, per the son had fell on "Tuesday", landing on their left hip, is 
still able to get around with their walker but has minimized general movement. Today as the enrollee was 
leaving the bathroom their eyes became glassy and they nearly passed out but was caught by their son. The 
enrollee was found to have possible left lower lobe infiltrate on chest x-ray. The enrollee denied chest pain, 
cough, wheezing, shortness of breath, fever or chills. The chest x-ray, interpreted by the doctor showed no 
acute pulmonary disease and left hip x-ray interpreted by the doctor showed no acute fracture. The assessment 
was status post mechanical fall, near syncope, mild azotemia, lactic acidosis and leukocytosis, suspected 
community-acquired pneumonia. The review has determined that the record did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the enrollees necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided January 2, 2022, to January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMDx testing provided on October 19, 2022. 
 
You asked the Plan to pay for the SelectMDx testing. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee did not meet criteria for the testing rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that this testing is only covered for men equal to or 
less than 75-year-old with a PSA greater than three and less than 10 10ng/mL and/or DRE findings are very 
suspicious for cancer. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee already has a diagnosis of 
prostate cancer. This means the enrollee did not meet criteria for the testing rendered. Based on this 
information, we decided that Medicare rules for coverage of the SelectMDx testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided on October 19, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. 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 FDA-
approved 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 Aranesp. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the drug is not being prescribed for a 
medically accepted indication. The review indicates that the requested use of Aranesp is not FDA-approved for 
the enrollees diagnosis. Its use is not supported by one of the major drug compendia or by clinical research 
that appears in a CMS-approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided April 19, 2022, to April 
25, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 19, 2022. The NOA was not received by the Plan. As more than 30 
days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services provided April 19, 2022, 
to April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDX-SCC test. 
 
You asked the Plan to pay for the DecisionDX-SCC test. You say that there is no other laboratory in the world 
that performs this test. The Plan denied your request. The Plan says that under the Medicare guidelines the 
DecisionDx-SCC is not medically necessary because it has not been approved as meeting Medicare's 
reasonable and necessary requirement via the MolDx technical assessment. The Plan follows Medicare rules. 
 
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 is not considered medically necessary. Our physician reviewer found that 
the enrollee has a diagnosis of squamous cell carcinoma of the skin of the forearm measuring 2.4 x 2.4 x 0.4 
cm. The tumor extended to the transected tissue edges following biopsy. The Medicare requirements for such 
testing were not met. The Decision DX-SCC measured theoretical risk of metastasis. The requirements exclude 
any such testing that determine risk for developing a disease or condition.  
 
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 November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 30, 2022. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services 
provided on December 30, 2022.