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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for SNF care is correct. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does 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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Pyschotropic testing panel provided on July 
14, 2021. 
 You asked the Plan to pay for the GeneSight Pyschotropic testing panel. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this testing service is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that combinatorial PGx tests, such as GeneSight, are 
not clearly shown to be more beneficial in drug selection than usual prescribing methods. Based on this 
information, we decided that Medicare rules for coverage of the GeneSight Pyschotropic testing panel have not 
been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Pyschotropic testing 
panel provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral exam and extractions to be provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve the oral surgeon services. You say that these services are necessary. The 
Plan denied your request. The Plan says your benefit does not cover the services of an oral surgeon. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit when provided by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve an oral exam and extractions to be provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopy, surgical, gastric restrictive procedure; 
longitudinal gastrectomy (ie, sleeve gastrectomy) for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that laparoscopic sleeve gastrectomy (LSG) can be 
covered for a BMI over 35 kg/m2. 
 
 
 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 a failure to document a BMI that more than 35 kg/m2. It ranges from 31.4 to 32.9 
kg/m2 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve 
gastrectomy) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat facet joint injection. 
 
You asked the Plan to pre-approve the requested facet joint injection. You say that you feel that this procedure 
should be allowed. The Plan denied your request. The Plan says you do not meet criteria for this treatment. 
 
The Plan follows Medicare rules. Medicare rules say that continued facet joint treatments require that pain be 
reduced by at least 80% and that the facet joint be the most likely pain generator. 
 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 facet joint injection. Our 
reviewer says that the requested second facet joint injection is not medically necessary. Our physician reviewer 
found the patient had diagnostic blocks that produced 70% pain relief. National Clinical Practice guidelines 
clearly state that diagnostic blocks should produce at least 80% pain relief. The patient has other probable pain 
generators that have not been addressed. The requested 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 requested facet joint injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a repeat facet joint injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) for sacroiliac joint pain 
(64625) provided on June 30, 2021. 
 
You asked the Plan to pay for the RFA for sacroiliac joint pain. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation used for sacroiliac joint 
pain is considered not medically necessary/investigational whether performed using traditional, cooled, or 
pulsed radiofrequency. Based on this information, we decided that Medicare rules for coverage of the RFA for 
sacroiliac joint pain have not been met. Therefore, we decided that the Plan does not have to pay for the 
radiofrequency ablation (RFA) for sacroiliac joint pain (64625) provided on June 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on October 1, 2021, to 
October 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy services provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-
network care. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on October 
1, 2021, to October 19, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for palliative treatment of skin manifestations of cutaneous T-
cell lymphoma (CTCL) provided to the enrollee on October 6, 2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the medical necessity 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 pay for the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found palliative treatment of skin manifestations of cutaneous T-cell lymphoma (CTCL) that has not 
responded to other therapy (apheresis) was requested to be continued, which had been used since 2018 and had 
led to her being able to end supplemental oxygen and hospitalizations. However, the records do not show that 
the patient has had a lung transplant or is participating in a study to meet LCD criteria.  
 
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 palliative treatment of skin manifestations of cutaneous T-cell lymphoma (CTCL) provided to 
the enrollee on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided to the enrollee on November 
1, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this might be covered under Part D. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. This 
was done as a preventive measure, which is not covered. Therefore, we decided that the Plan does not have to 
pay for immunization services provided to the enrollee on November 1, 2021.  
 
Benefits for the services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on December 1, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the billed code 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 19380 is "Revision of reconstructed breast (eg, 
significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or 
significant capsular revision combined with soft tissue excision in implant-based reconstruction)." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report does not include 
sufficient documentation to confirm all criteria per CPT code description, and that the NCCI Policy Manual 
criteria have been met. The documentation supports tissue removal; however, the remaining criteria cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Radiologic examination (71045) provided on May 18, 
2021. 
 
You asked the Plan to pay for code 71045. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must confirm that Medicare 
coverage criteria have been met. 
  
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that two separate chest x-rays were provided May 18, 2021. The file shows that the Plan paid for one set of chest x-
rays (1 unit of 71045) provided on May 18, 2021. Therefore, we decided that the Plan does not have to pay for 
the Radiologic examination (71045) provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services (64450) provided on August 4, 2021. 
 
You asked the Plan to pay for the injection services. You say that you would like this claim reprocessed for 
medical necessity. The Plan denied your request. The Plan says this claim has denied correctly per Medicare 
rules. 
 
The Plan must follow Medicare rules. Medicare rules say that S61.211A, defined as Laceration without foreign 
body of left index finger without damage to nail, initial encounter, and S56.422A, defined as Laceration of 
extensor muscle, fascia and tendon of left index finger at forearm level, initial encounter, will not be covered 
for the billed current procedural terminology code 64450. 
 
We looked at the file and Medicare rules. In this case, the diagnoses that have been billed are not covered for 
the billed CPT procedure 64450. Based on this information, we decided that Medicare rules for coverage of the 
injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection 
services (64450) provided on August 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on May 27, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code is not supported in the medical records submitted. 
 
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 37233 is "Revascularization, endovascular, open or 
percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty 
within the same vessel, when performed (List separately in addition to code for primary procedure)." 
 
 
 
 
 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found a Command wire was advanced to the 
distal peroneal artery and a Volcano 0.018 IVUS catheter was used to perform intravascular ultrasound of the 
left external iliac, femoral popliteal, tibioperoneal trunk, and peroneal arteries. The intravascular ultrasound 
confirmed the angiographic findings. A 0.9mm Spectranetics laser was used to perform laser atherectomy of 
the femoral popliteal, tibioperoneal trunk, and peroneal arteries. This was followed by balloon angioplasty of 
the tibioperoneal trunk, and peroneal arteries using a Bard Ultraverse 3 mm x 40 mm balloon. Repeat 
angiography demonstrated 0% residual stenosis. Per AMA Principles of CPT Coding 9th edition 2017, even if 
a nonselective catheter placement is performed first, the highest selective placement within each vascular 
family is the determining factor for the level of coding. In the clinical documents submitted for review, the 
vessels treated, as described (tibioperoneal trunk and peroneal artery), comprise a single vascular family and no 
additional vessels may be coded for. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on May 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on November 15, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you have been seeing this provider for 20 years and 
do not want to change psychiatrists as it would involve you change a series of other doctors and changes of 
plans. You also say that you have been receiving paid claims this entire year despite him being out-of-network. 
The Plan denied your request. The Plan says this service was rendered by a non-participating provider without 
prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on  
November 15, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not 
reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The 
enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and 
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination 
of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary 
services on an inpatient basis, in a skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (CGM) provided 
on October 4, 2021. 
 
You asked the Plan to pay for the therapeutic CGM. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the documentation submitted did not 
include a valid proof of delivery or a delivery ticket to indicate the specific supplies. 
 
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.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the documentation provided does not indicate that the ordering physician discussed the 
medical necessity of the ordered CGM with the enrollee. 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 therapeutic continuous glucose monitor (CGM) provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the introduction of needle or intracatheter (36000) provided 
on August 8, 2021. 
 
You asked the Plan to pay for the introduction of needle or intracatheter (36000). You say that the provider was 
requested by the facility to provide services to the member. You say that this claim should be paid if the facility 
and surgeon's claim was paid. The Plan denied your request. The Plan says procedure codes 00840, 36620, 
36556, 76942 have been overturned and procedure code 36000 remains denied as it is inclusive to procedure 
code 00840. 
 
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 36000 is introduction of needle or intracatheter, vein. 
 
We find that CPT code 36000 is not supported in the medical record. Specifically, CPT code 36000 has a status 
indicator of B. This means that CPT code 36000 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the introduction of needle or intracatheter 
(36000) have not been met. Therefore, we decided that the Plan does not have to pay for the introduction of 
needle or intracatheter (36000) provided on August 8, 2021.