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

 
We decided that the Plan does not have to pre-approve visual field assessment, with concurrent real time data 
analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up 
to 30 days (Foresee Home AMD Monitoring) (0379T). 
 
You asked the Plan to pre-approve Foresee Home AMD Monitoring. You say that the enrollee needs these 
service. The Plan denied your request. The Plan says the requested service 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 Foresee Home AMD Monitoring. Our 
reviewer says that the requested Foresee Home AMD Monitoring is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Foresee Home AMD monitoring program is 
considered investigational/experimental as additional clinical studies are needed to demonstrate that it affects visual outcomes. Therefore, the reviewer found that the requested services are 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 Foresee Home AMD Monitoring have not been met. Therefore, we decided that 
the Plan does not have to pre-approve visual field assessment, with concurrent real time data analysis and 
accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days 
(Foresee Home AMD Monitoring) (0379T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an OON sleep study. You say that you do not understand why the requested 
provider is considered OON. The Plan denied your request. The Plan says the requested service can be 
provided by an in-network provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services with an OON provider. Therefore, we decided that the Plan does not have to 
pre-approve a sleep study to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 20, 2021, billed with 
codes 81408, 81401, 81355, 81328, 81291, 81240, 81231,81227, 81226, 81225 and 81241. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test 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. In addition, this test is considered a screening and was not medically 
necessary. 
 
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 20, 2021, billed with codes 81408, 81401, 81355, 81328, 81291, 81240, 81231,81227, 81226, 81225 
and 81241.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 5, 2022, 
through March 6, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the NOA was not received timely and the admission date on the denied claim does 
not match the NOA admission date. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The Plan received a valid NOA on May 26, 2022, which is after the date the claim for dates of services 
February 5, 2022, through March 6, 2022, was received on April 18, 2022, and after the claim denial date of 
May 10, 2022. The admission date on the denied claim is entered as June 10, 2021, which does not match the 
admission date of January 6, 2022, entered correctly on the NOA. Therefore, we decided that the Plan does not 
have to pay for the home health services provided from February 5, 2022, through March 6, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the direct skilled nursing services of a registered nurse (RN) (G0299), 
direct skilled nursing services of a licensed practical nurse (LPN) (G0300), and waterproof tape (A4452) 
provided from December 1, 2021, to December 31, 2021. 
 
You asked the Plan to pay for the direct skilled nursing services of an LPN and RN and waterproof tape. You 
say that you would like to verify that this claim processed correctly in-network, per the contract agreement. The 
Plan denied your request. The Plan says that the number of days or units of service exceeds the acceptable 
maximum. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the citation the Plan used is incorrect, and references ambulance 
services. The correct citation does not specifically place a limit of 30 days on home health services, but gives 
structure to how the services are paid. Consequently, the Plan has not substantiated their denial of payment in 
this case. Therefore, we decided that the Plan has to pay for the direct skilled nursing services of a registered 
nurse (RN) (G0299), direct skilled nursing services of a licensed practical nurse (LPN) (G0300), and 
waterproof tape (A4452) provided from December 1, 2021, to December 31, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (CPT code 99232) provided on 
September 15, 2020. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the claim should be paid. The Plan 
denied your request. The Plan says the services are not covered as 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. 
 
Code 99232 billed by the provider for date of service September 15, 2020, denied because it was reported with 
another evaluation and management service on the same day performed by the same provider. Per review, code 
99233 was already processed and paid on October 18, 2020, to the same provider. Both the claims were billed 
under billing group Hospitalist Medicine Physicians, NPI. The documentation received does not indicate the 
billing provider performed evaluation and management service more than once on date of service September 15, 2020. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (CPT code 
99232) provided on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable neurostimulator 
 
You asked the Plan to pre-approve an implantable neurostimulator. You say that an implantable 
neurostimulator is medically necessary. The Plan denied your request. The Plan says an implantable 
neurostimulator does not meet the Medicare coverage 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 pre-approve an implantable neurostimulator. Our 
reviewer says that the requested implantable neurostimulator is not considered medically reasonable and 
necessary. Our physician reviewer found that this is considered an experimental/investigational 
procedure. Therefore, the request is deemed 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 an implantable neurostimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an implantable neurostimulator
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 
10, 2021, to July 9, 2021. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, a RAP was 
not submitted for the period of care at issue. Therefore, we decided that the Plan does not have to pay for the 
home health services provided to the enrollee from June 10, 2021, to July 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on July 26, 2021, 
to July 27, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission was medically 
necessary. The Plan denied your request. The Plan says the medical criteria for an inpatient admission were not 
met. 
 
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 it is not reasonably expected that the enrollee's stay 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 on July 26, 2021, to July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. The Plan denied your request. The Plan says 
approval of an MRI of the lumbar spine is not considered medically necessary. The Plan also say that you have 
not completed six weeks of provider directed treatment, and there was not contact with your provider after 
completing treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is not reasonable and necessary. Our physician reviewer found 
the lumbar spine x-rays from March 11, 2021, showed degenerative changes. Neurological exam is normal, and 
normal reflexes and lower extremity strength. No red flags. Our reviewer found that there has been no 
conservative management including a 6-week trial of supervised physical therapy that has been attempted. Our 
physician reviewer also found with an absent conservative treatment attempt and lack of red flags, an 
immediate MRI is not medically necessary at this time. 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cardiovascular hereditary panel and a 
comprehensive pharmacogenomic (PGx) panel provided on April 25, 2022. 
 
You asked the Plan to pay for genetic testing. You say that these services were medically necessary and were 
ordered by the enrollee's physician. The Plan denied your request. The Plan says these tests were 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 pay for genetic testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records indicate that there are no current side effects from the enrollee's medications 
and there is no documentation of newly planned treatment or documentation of how these tests will impact the 
clinical management of this enrollee. The enrollee does not have rigorous disease-appropriate phenotyping to 
establish clinical diagnosis or suspected diagnosis for which the test results would directly impact the 
management of the enrollees condition prior to ordering the test and there is no evidence that the gene-disease 
association is evaluated by the evidence-based, transparent, peer-reviewed process which meets the required 
criteria. Based on Medicare guidelines, the requested tests were not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the comprehensive cardiovascular hereditary panel and a comprehensive pharmacogenomic 
(PGx) panel provided on April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OncotypeDX testing (81519) provided on May 25, 2022. 
 
You asked the Plan to pay for the OncotypeDX testing. You say that the claim should be paid. The Plan denied 
your request. The Plan says the OncotypeDX test was not medically necessary. The Plan states the enrollee's 
breast cancer status is unknown. 
 
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 OncotypeDX testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation did not clearly show the status of the enrollee's breast 
cancer. There was no clear staging completed, no node status, and there was no indication that the results of the 
genetic testing would directly change the treatment plan recommended to this enrollee. Therefore, without 
sufficient support made for this request, the OncotypeDX test will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the OncotypeDX testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the OncotypeDX testing (81519) provided on May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services (procedure code 64415) provided to the 
enrollee on April 22, 2022. 
 
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 Current Procedural Terminology (CPT) code 64415-59-RT (1 Unit) remains 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 64415 is "Injection(s), anesthetic agent(s) and/or steroid; 
brachial plexus." 
 
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 that there is a lack of required 
documentation to support CPT 64415. There is no documentation of a surgeon's note requesting a post-
operative pain block. 
 
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 injection services (procedure code 64415) provided to the enrollee on April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous spacer (ISS) device 
(22869). 
 
You asked the Plan to pre-approve Vertiflex Superion device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested device 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 Vertiflex Superion device. Our 
reviewer says that the requested Vertiflex Superion device is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested device is considered experimental at this 
time. Therefore, the reviewer found that the requested device 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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion interspinous spacer (ISS) device (22869).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure, 1 or more areas, each 15 minutes 
(97110) provided on June 20, 2022. 
 
You asked the Plan to pay for the physical therapy exercises. You say that this claim was denied incorrectly. 
The Plan denied your request. The Plan says the therapy service modifier requires a therapy service revenue 
code. 
 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 reviewed the file and Medicare rules. In this case the claim was billed with a GP modifier but was not 
billed with an appropriate revenue code. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy exercises have not been met. Therefore, we decided that the Plan does not 
have to pay for the therapeutic procedure, 1 or more areas, each 15 minutes (97110) provided on June 20, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cystectomy with continent diversion, radical retropubic 
prostatectomy, and removal of pelvis lymph nodes to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve cystectomy with continent diversion, radical retropubic prostatectomy, and 
removal of pelvis lymph nodes to be provided by an OON provider. You say that the services are necessary. 
The Plan denied your request. The Plan says there are in-network providers that are able to provide these 
services. Therefore, coverage criteria have not been met. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve cystectomy with continent diversion, radical retropubic prostatectomy, and removal of pelvis lymph nodes to 
be provided by an out-of-network (OON) provider.