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

 
We decided that the Plan does not have to pay for the lab services provided on January 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that drug testing is needed to monitor possible opioid 
abuse. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. In this  case, the claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro myoelectric limb orthosis for the enrollee. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this would be considered experimental and 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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the current clinical guidelines designate robotic therapy to be of "uncertain utility compared with 
dose-matched conventional upper limb exercise therapies" with unproven benefit in the home 
environment. There is no documentation that MyoPro myoelectric limb orthosis at issue in this case meets 
Medicare criteria for medically reasonable and necessary per Social Security Act, Section 1862(a)1(A). 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MyoPro myoelectric limb orthosis for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the lab does not have a 
contract with the dialysis facility. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on 
February 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 20, 2022, 
to March 21, 2022. 
 
You asked the Plan to pay for the home health services. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the home health services provided 
from February 20, 2022, to March 21, 2022, have been met. In this case, the notice of admission (NOA) is 
required to process this claim and is missing from the documents submitted. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from February 20, 2022, to March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FoundationOne CDx genetic test. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has declined chemotherapy cancer treatment. 
 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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case , the record indicates that the enrollee has pancreatic cancer. The record indicates that the 
enrollee has declined to proceed with chemotherapy treatment. The elements of the coverage criteria 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the FoundationOne CDx genetic test.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durysta. 
 
You asked the Plan to pre-approve Durysta. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested use is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Durysta. Our reviewer says that the 
requested use of Durysta is not supported. Our physician reviewer found repeat Durysta implantation for 
primary open-angle glaucoma is not Food and Drug Administration-approved or supported by the major drug 
compendia or clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durysta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durysta.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal injection/therapeutic facet joint injection 
(procedure code 64493). 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request cannot be approved. 
 
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review has determined that there have not been two diagnostic medial branch blocks (MBBs). 
Therefore, the criteria for therapeutic facet joint injections have not been met. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal injection/therapeutic facet joint injection (procedure code 64493).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mitral valve repair (33430) and inpatient admission. 
 
You asked the Plan to pre-approve mitral valve repair (33430) and inpatient admission. You say that the 
requested surgical mitral valve repair (33430) and inpatient admission is medically necessary. The Plan denied 
your request. The Plan says the requested surgical mitral valve repair (33430) and inpatient admission 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 mitral valve repair (33430) and 
inpatient admission. Our reviewer says that the requested surgical mitral valve repair (33430) and inpatient 
admission is not medically necessary. Our physician reviewer found the enrollees June 2022 echocardiogram 
shows mild mitral stenosis and mild mitral regurgitation. Cardiology office visit describes absence of 
cardiovascular symptoms. As such, the documentation would not suggest that the mitral valve disease is of 
sufficient severity to warrant valve replacement. As a result, at this time mitral valve repair would not be 
considered medically reasonable 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 mitral valve repair (33430) and inpatient admission have not been met. 
Therefore, we decided that the Plan does not have to pre-approve mitral valve repair (33430) and inpatient 
admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation benefits for 2022. 
 
You asked the Plan to provide additional transportation. You say that you need additional transportation to get 
to your appointments and maintain your health. You also say you have gym benefits but cannot use them 
without transportation. The Plan denied your request. The Plan says your benefit covers a maximum of 48 
routine transportation trips per year. Additional trips are not a covered benefit. 
 
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 48 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 provide additional routine transportation benefits for 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft (20930), arthrodesis (22551, 22552), anterior 
segmentation (22846) and insertion of interbody biomechanical device (22853). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no documentation of the injections received, the duration 
of physical therapy, or the other non-operative treatments performed, other than the provider stating they were 
performed. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is not enough 
clinical information in the records to justify fusion surgery. More information is needed. There is no indication 
how much physical therapy was performed. Our physician reviewer found that your condition does not meet 
criteria for coverage of these services. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve allograft (20930), arthrodesis (22551, 22552), anterior segmentation (22846) and insertion 
of interbody biomechanical device (22853).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of long-term 
acute care admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute care and is currently unstable for transfer to the LTACH. 
 
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 was admitted for sepsis in the setting of an infected defibrillator lead and 
has had a complicated hospital course including acute kidney injury. The record indicates that the enrollee still 
requires acute critical care services. The medical record does not indicate that the enrollee requires services that 
they are not currently receiving but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist visit. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the 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 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 
specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vascular embolization or occlusion, inclusive of all 
radiological supervision and interpretation (37242) and intra-arterial-intra-aortic vascular injection (36140) 
provided August 20, 2021 
 
You asked the Plan to pay for the surgical services. You say that please see attached waiver with all medical 
records for assistant surgeon. Please reprocess assistant surgeon for payment. The Plan denied your request. 
The Plan says services of an assistant surgeon, co-surgeon, or surgical team are not covered for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 37242 and 36140. The Medicare Fee Schedule Database contains a 
surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is 
not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage 
criteria for the surgical services have not been met. Therefore, we decided that the Plan does not have to pay 
for vascular embolization or occlusion, inclusive of all radiological supervision and interpretation (37242) and 
intra-arterial-intra-aortic vascular injection (36140) provided August 20, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foldable power scooter (K0801). 
 
You asked the Plan to pre-approve a foldable power scooter. You say that you need help getting around outside 
of the house. You also say the other scooter is on the 2nd floor and cannot be transported off the 2nd floor. The 
Plan denied your request. The Plan says you already have a power wheelchair which serves the same purpose 
as a foldable scooter. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. a power wheelchair serves the same purpose as a foldable 
power scooter. Therefore, we decided that the Plan does not have to pre-approve a foldable power scooter 
(K0801).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on February 14, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for chiropractic services. You say that you were reimbursed for the same services 
last year so you figured you would be reimbursed again this time. The Plan denied your request. The Plan says 
services were obtained out-of-network and were not authorized. 
 
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 chiropractic services provided on February 14, 
2022, by an out-of-network 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for respiratory failure and pulmonary edema. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Medically necessary care can be provided in a different 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the procedure. You say that this procedure improves the quality of life of 
patients suffering from vertebrogenic low back pain. The Plan denied your request. The Plan says there are not 
enough studies on Intracept to show it is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the Intracept procedure (64628, 64629).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) massage therapy visits. 
 
You asked the Plan to pre-approve massage therapy. You say that you are in pain and your physical therapist 
recommended these services. There are no in-network providers who can perform these services. The Plan 
denied your request. The Plan says massage therapy is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve eight (8) massage therapy visits.