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

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service January 13, 
2022. 
 You asked the Plan to pay for procedure code 71045. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says payment for code 71045 is bundled 
into payment for code 32555. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 
is a column II code to column I code 32555. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71045 billed for date of service January 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services provided on March 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the out-of-network ophthalmology services. You say that you ended up staying 
in Florida longer than anticipated and you get monthly eye injections.  Because of this, you had to have the 
injections in Florida. The Plan denied your request. The Plan says these routine services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that if you need medical care that is not available from network providers, the provider or you MUST 
always obtain prior authorization (approval in advance) before you receive any out-of-network non-emergency 
medical care. If prior authorization is not obtained, you may have to pay for these services yourself. 
 
 
 
 
 
 The provider in this case is not a network provider with the Plan. 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 ophthalmology services provided on March 3, 2022, by an out-
of-network (OON) provider.
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 you broke your back, and you cannot walk. You 
need rehabilitation so you can take care of yourself again. The Plan denied your request. The Plan says the 
documentation does not show that the enrollee needs to be seen by a rehabilitation doctor at least 3 times a 
week, or that the enrollee will need and are able to take part in 3 hours of therapy a day at least 5 days a week 
or 15 hours per week. The services the enrollee needs can be provided safely in other settings like 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 that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or 
documented. At the high current functional level, the enrollee does not need 3 hours a day 5 days a week of 
therapies. 
 
The lack of medical complexity and lack of nursing needs and high functional mobility do not support an acute 
hospital inpatient rehabilitation admission with an interdisciplinary approach to rehabilitation care. 
Documentation does not support the medical necessity for admission to an IRF. The enrollee's rehabilitation 
needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve colon capsule endoscopy (CCE) services (91112, 
91110, 91299). 
 
You asked the Plan to pre-approve CCE services. You say that these services are medically necessary, and this 
procedure has been shown to be safe and effective. The Plan denied your request. The Plan says there is not 
adequate evidence that the requested procedure is likely to provide reliable diagnostic information that will 
improve your outcome. 
 
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 CCE services. Our reviewer says that 
the requested capsule endoscopy services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the data provided supports radiographic remission of your Crohn's disease 
on maintenance vedolizumab. Whereas capsule endoscopy has value in some patients for assessing Crohns 
activity in the small bowel, the risk of the capsule becoming impacted with your prior history of acute small 
bowel obstruction means that CCE cannot be used in this case. It is proposed that you have surgical 
management with directed bowel resection at the location of impaction of a patency capsule, which you are 
advocating you ingest. This approach is a difficult and possibly dangerous approach because this method would 
not be able to distinguish dysmotility causing what appears to be an obstruction (which would not require 
surgery) from mechanical stenosis which would require emergency surgery if a bowel blockage were to result 
from capsule ingestion. The medical necessity, safety, and appropriateness of the proposed service is not 
demonstrated for 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 CCE services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve colon capsule endoscopy (CCE) services (91112, 91110, 91299).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided January 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says no separate payment is made for 
the laboratory services in this case. 
 
 
 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided January 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger finger release surgery, tendon sheath incision eg, 
for trigger finger (20655). 
 
You asked the Plan to pre-approve the surgical procedure. You say that say the medical records provided 
support the necessity of the requested services. The Plan denied your request. The Plan says the medical need 
for surgery is not shown in the record and the medical necessity criteria for 26055 is not met. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this 66-year-old male was being treated for trigger finger of the left ring finger. He 
presented with triggering of the left ring finger for the past several months. Because of the triggering, he is 
having difficulty using the left hand. The exam reveals he has triggering of the ring finger of the left hand. 
However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the requested trigger finger release surgery, tendon sheath incision (CPT 
20655), 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve trigger finger release surgery, tendon sheath incision eg, for trigger finger 
(20655).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that oral bisphosphonates would not be appropriate due to 
safety concerns of further esophageal damage. The Plan denied your request. The Plan says the enrollee does 
not meet the medical necessity criteria of prior trial and failure of oral or intravenous bisphosphonates, and the 
enrollee does not have any contraindications to bisphosphonate therapy. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that Prolia is 
not reasonable and necessary. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that the 
enrollee has an absolute contraindication to, or would have an adverse effect from the Plan's preferred step one 
alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. Our physician 
reviewer also found that the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on April 7, 2022. 
 
You asked the Plan to pay for the refraction. You say that you did not ask for glasses or a refraction procedure 
on this date of service. The Plan denied your request. The Plan says the eye refraction service is not a covered 
benefit since it was performed with a medical diagnosis. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eye refractions during a routine exam. 
 
 
 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you received a medical eye exam for the 
diagnosis of age-related nuclear cataract, left eye. Based on this information, we decided that the Plan's rules 
for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for 
the eye refraction (92015) provided on April 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrocentesis services coded 20611 provided on 
November 24, 2021. 
 
You asked the Plan to pay for the arthrocentesis services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says there is insufficient documentation to 
corroborate the services billed. 
 
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 20611 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording 
and reporting. 
 
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 arthrocentesis services. Our reviewer says that the documentation does not support for the billed CPT code 20611. Our reviewer found that the procedure report 
documents "Procedure: One adequate needle placement was achieved a 2.5cc pre-filled GelSyn-3 - 1 units."  
Documentation does not support ultrasound was used for this procedure, and therefore cannot be verified. In 
this case, a more appropriate CPT code should be reported for service documented. 
 
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 arthrocentesis services have not been met. Therefore, we decided that the 
Plan does not have to pay for the arthrocentesis services coded 20611 provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says the facet joint injections do not meet the Medicare 
LCD coverage criteria. 
 
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 pre-approve facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that in this case, there is 
evidence of radiculopathy. The review has determined that the requested facet joint injections do not meet the 
Medicare LCD coverage 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says this procedure is 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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current evidence-based medical guideline and peer-reviewed literature do not fully 
support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a 
lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this 
enrollees medical 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
February 1, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. The next generation sequence testing (NGS) testing panel 
performed included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is 
statutorily excluded service. In addition to single gene testing, panels that include the FANCC gene are 
statutorily excluded service. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne CDx (F1CDx) test (0037U) provided February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
not enough research to show its safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services.  Our physician 
reviewer found that interspinous stabilization devices remain experimental. More research is needed to show its 
effectiveness. Therefore, the request 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee is not medically stable to transfer to 
another level of care. The Plan says that the enrollee has not finished his full course of care in the hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be still unstable requiring high flow oxygen and without trach 
and requires short-term additional acute care services that can safely be administered at the current facility until 
more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that 
are not already available at the current facility. Transfer to LTACH is not medically necessary at this time as 
the enrollee is not stable for transfer and as it would not be clinically advantageous. Completion of treatment at 
the current facility is recommended. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 51784-26 billed for date of service October 
6, 2021. 
 You asked the Plan to pay for procedure code 51784-26. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 51784-26 is bundled into 
payment for code 51792. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
51784-26 is a column II code to column I code 51792 with a modifier indicator of 0. The column II code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 51784-26 billed for date of service October 6, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported case metal crown (D6063) and 
implant-supported porcelain/ceramic crown (D6065) for tooth #5, #6, #7, #8, #9, #10, #11, #12, and #13. 
 
You asked the Plan to pre-approve the metal crown and porcelain/ceramic crown.. You say that you do not feel 
well and cannot eat well. The Plan denied your request. The Plan says these services are not covered under 
your benefit plan. 
 
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. Therefore, we decided that the Plan does not have to pre-approve 
abutment supported case metal crown (D6063) and implant-supported porcelain/ceramic crown (D6065) for 
tooth #5, #6, #7, #8, #9, #10, #11, #12, and #13.