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

 
We decided that the Plan does not have to pay for code 49905-AS billed for date of service April 8, 2022. 
 
You asked the Plan to pay for code 49905-AS. You say that the medical records support payment for this code. 
The Plan denied your request. The Plan says code 49905-AS is not supported in the medical record. 
 
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 49905-AS is Intra-abdominal omental flap (listed 
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 code 49905-AS. Our reviewer says that code 49905-AS is 
not supported in the medical record. Our reviewer found the operative report does not describe an intra-
abdominal omental flap to include, a physician dissection of a portion of the omentum from over the transverse 
colon. The freed portion of omentum is then rotated (leaving the main blood supply intact), placed into the pelvis to exclude to the small bowel or fill an intra-abdominal defect, and then sutured to the pelvic sidewall 
and/or organ(s). The reviewer was unable to cite to them report as dissection, placement and suturing of 
omentum into the pelvis was not documented in the operative report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 49905-AS have not been met. Therefore, we decided that the Plan does not 
have to pay for code 49905-AS billed for date of service April 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 13, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this was not a bundled charge. The Plan 
denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (ESIs) (64483, 64484). 
 
You asked the Plan to pre-approve ESIs. You say that the enrollee reports that their symptoms have not 
improved despite physical therapy and medications. You say that their symptoms are getting worse. You also say that during their physical exams, there were some abnormalities included in the visit notes. The Plan denied 
your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the 3 requirements are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve ESIs. Our reviewer says that the 
requested ESIs are not medically necessary. Our physician reviewer found the provided documentation does 
not indicate there was radiologic documentation of canal impingement by severe degenerative disc disease, 
central canal stenosis or osteophytes. Therefore, the reviewer found that the requested ESIs 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 ESIs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve epidural steroid injections (ESIs) (64483, 64484).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Initial nursing facility care provided on June 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Initial nursing facility care. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 Initial nursing facility care provided on June 16, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME provided on March 11, 2022. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Code A5500-RT-KX (1 Unit) 
remains not supported. The documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. Therefore, the billed supply 
code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional 
information. Healthcare Common Procedure Coding System (HCPCS) code A5500-LT-KX (1 Unit) remains 
not supported. The documentation submitted did not include an itemized shipping/billing invoice to indicate 
the specific supplies, or proof of delivery for the billed date of service. Therefore, the billed supply code 
cannot be verified. It is noted that multiple attempts were made to contact the provider for additional 
information. HCPCS code A5512-RT-KX (3 Units) remains not supported. The documentation submitted did 
not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the 
billed date of service. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts 
were made to contact the provider for additional information. HCPCS code A5512-LT-KX (3 Units) remains 
not supported. The documentation submitted did not include an itemized shipping/billing invoice to indicate 
the specific supplies, or proof of delivery for the billed date of service. Therefore, the billed supply code cannot 
be verified. Therefore, we decided that the Plan does not have to pay for the DME provided on March 11, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that the record indicates that the enrollee is improving but still require acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that she is 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. 
 
 
 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the records provided support the need 
for radiofrequency ablation. The Plan denied your request. The Plan says the services in dispute are non-
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation used for sacro-iliac joint 
pain is considered not medically necessary. 
 
We looked at the file and Medicare rules. The records show that the radiofrequency ablation services being 
requested would be used for sacro-iliac joint pain. Based on this information, we decided that Medicare rules 
for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs this device for his 
worsening heart failure. The Plan denied your request. The Plan says there is not enough evidence this device 
would improve the enrollee's condition. 
 
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 the enrollee has recurrent congestive heart failure (CHF). Published expert opinion in the 
cardiology literature is supportive of the clinical usefulness of the CardioMEMS device. There remains a dearth 
of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollees clinical management. 
 
 
 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 a CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus pharmacogenomics panel 81225, 81226, 81227, 
81230, 81231, 81381, 81381 provided May 19, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this letter documents medical necessity for the 
enrollee based on the intent to use the test results as a tool to assist in the physician's evidence-based practice 
model. The Plan denied your request. The Plan says the authorization was not approved. The request is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to 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 in this case the enrollee underwent pharmacogenetic testing for depression. This testing was not 
done for the following indication: "Alternative laboratory or clinical tests to definitively diagnose the 
disorder/identify the condition are unavailable or results are clearly equivocal". Rather, this type of testing is 
not done for the diagnosis of a disorder or to identify the nature of the disorder. Nor is this testing required for 
the prescription/administration of any specific medication(s) [e.g., testing prior to the use of clopidogrel.] In as 
much, it cannot be said that the testing performed would have met criteria for coverage. 
 
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 Tempus pharmacogenomics panel 81225, 81226, 81227, 81230, 81231, 81381, 81381 
provided May 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and progressive lenses (V2781) provided 
on June 9, 2022. 
 
You asked the Plan to pay for the frames and progressive lenses. You say that you should be reimbursed more 
for these items. The Plan denied your request. The Plan says progressive lenses are not covered under 
Medicare. The Plan also says that you have exhausted your $200 allowance for routine prescription eyewear. 
 
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 up to a $200 allowance per year for routine prescription eyewear. 
 
 
 
 
 We looked at the file and the Plan's rules. Specifically, your $200 eyewear allowance was exhausted on your 
eyewear purchases from June 9, 2022, and June 11, 2022, and you are responsible for the remaining amount. 
Based on this information, we decided that the Plan's rules for coverage of the frames and progressive lenses 
have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) and 
progressive lenses (V2781) provided on June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Next Generation Sequencing (0037U) provided on July 
8, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that this should be covered. The Plan denied your 
request. The Plan says the plan denied the service correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing is considered 
medically necessary for specific diagnosis codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing have not been met. Specifically, the file does not support that the enrollee 
had a coverable diagnosis. Therefore, we decided that the Plan does not have to pay for the Next Generation 
Sequencing (0037U) provided on July 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are 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 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 in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee can receive further 
services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that it is necessary for you to 
receive additional routine transportation trips to your dialysis appointments. The Plan denied your request. The 
Plan says the benefit for routine transportation has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right knee arthroscopy. 
 
You asked the Plan to pre-approve a right knee arthroscopy. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested right knee arthroscopy is 
not medically reasonable and 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 a right knee arthroscopy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 69-year-old female being treated for unspecified internal 
derangement of the right knee and unilateral primary osteoarthritis of the right knee. She presented with pain in 
her right knee on the medial side. The exam reveals a mild antalgic gait. There is trace effusion. The knee range 
of motion is approximately 2-120. There is medial joint line tenderness. Anterior drawer is 1+. 
 
In this case, the diagnostic studies provided (including an X-ray from April 1, 2022, and magnetic resonance 
imaging (MRI) scan from August 2, 2022) demonstrate relatively severe arthritis in the right knee. Significant mechanical issues are also not evident. 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. Therefore, the 
requested right knee arthroscopy, 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 a right knee arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a right knee arthroscopy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging. 
 
You asked the Plan to pre-approve a myocardial perfusion imaging. The Plan denied your request. The Plan 
says the requested myocardial perfusion imaging is denied based on lack of medical necessity for the service. 
 
The Plan follows Medicare rules. Medicare rules say that tests that are anticipated to provide information 
duplicative of another test already performed will be denied as not 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 a myocardial perfusion imaging. Our 
reviewer says that a myocardial perfusion imaging is not reasonable and necessary for the enrollee. Our 
physician reviewer found the enrollee has palpitations and atrial fibrillation. There is no history of chest pain. 
Our reviewer found that there is no evidence provided that would support the need for radionuclide stress 
testing. Our physician reviewer also found that there is insufficient documentation to support the medical 
necessity for the requested cardiac stress testing in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a myocardial perfusion imaging.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided from August 30, 2021, 
to September 1, 2021. 
 
You asked the Plan to pay for outpatient hospital care. You say that outpatient observation was ordered after 
this necessary procedure, and the status cannot be changed at this time. The Plan denied your request. The Plan 
says that procedure 35840 is an inpatient-only procedure which was billed on an outpatient hospital claim. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no payment under the OPPS for services 
that CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in 
the OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule. The rules 
say that when an inpatient-only procedure is billed on an outpatient claim, the service is denied, and all other 
line items are denied. 
 
We looked at the file and Medicare rules. In this case, an inpatient-only service was billed on an outpatient 
hospital claim. Based on this information, we decided that Medicare rules for coverage of outpatient hospital 
care have not been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital 
services provided from August 30, 2021, to September 1, 2021.