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

 
We decided that the Plan does not have to pay for diagnostic laboratory services (81479) provided on March 8, 
2022. 
 
You asked the Plan to pay for laboratory services. You say that the in-network provider ordered a blood biopsy 
and the Guardant360 test in order to assist determining the optimal treatment options for the enrollee. Along 
with ordering the test, the provider, signed a statement of medical necessity demonstrating that the 
Guardant360 was required in order to determine the optimal treatment pathway for the enrollee. The Plan 
denied your request. The Plan says this test is covered when the enrollee has not previously received genetic 
testing for the disease/condition. Records show this test was approved on July 12, 2021. Multiple attempts were 
made to understand why it needs to be repeated and how these test results impacted treatment. No additional 
information was received; therefore, the denial is upheld. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic genetic testing for a disease should be 
performed once in a lifetime. 
 
We looked at the file and Medicare rules. The LCD confirms that diagnostic genetic testing for a disease should 
be performed once in a lifetime. The Plan requested additional information asking why the test needed to be 
repeated and no information was received. The records show that the enrollee previously had this test done on 
July 12, 2021; therefore, the enrollee does not meet coverage criteria for the requested genetic testing. Based on 
this information, we decided that Medicare rules for coverage of laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for diagnostic laboratory services (81479) provided 
on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical facet joint injections. 
 
You asked the Plan to pre-approve cervical facet joint injections. You say that cervical facet joint injections are 
medically necessary. The Plan denied your request. The Plan says the requested cervical 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 cervical facet joint injections. Our 
reviewer says that cervical facet joint injections are not medically necessary. Our physician reviewer found that 
there is no physical examination of the neck recorded. The physical therapy is noted to be directed at the 
enrollees carpal tunnel and not the cervical area. The enrollees magnetic resonance imaging shows multi-level 
cervical degenerative disc disease, spinal stenosis as well as facet arthropathy. The enrollee has had multiple 
prior facet injections. There is no documentation of the neck exam. No motor, sensory, or reflexes data is 
recorded. There are other pain generators. Doing two different pain interventions at the same session is not in 
keeping with CMS standards. Therefore, the request is not deemed 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 cervical facet joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve cervical facet joint injections.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on January 3, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the enrollee's physician ordered ambulance transportation, and you would like this claim to be reconsidered for 
payment. The Plan denied your request. The Plan says this claim does not meet the requirements for coverage. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the non-emergency ambulance 
transportation and ground mileage. Our physician reviewer found the record does not indicate that 
the enrollee's clinical condition is such that other methods of transport, such as stretcher transport, were 
contraindicated or that the expertise, services and lifesaving and life-sustaining equipment that only a fully-
equipped ambulance can provide was required. Our reviewer found that the record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Our physician 
reviewer also found that the elements of the coverage criteria are not satisfied, and 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 the non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services provided on June 1, 2022. 
 
You asked the Plan to pay for the office services. You say that the claim should be paid. The Plan denied your 
request. The Plan says this service is included in the global surgery package. 
 
The Plan must follow Medicare rules. The rules say that The Medicare Fee Schedule Data Base (MFSDB) 
provides the postoperative periods that apply to each surgical procedure. If there is an indicator of 000, 
postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office services have not been met. Surgery procedure 56620 has a global value of 090 on the 
Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule (NPFS) Relative Value 
(RVU) file. This is a major procedure that has a global surgery period of 90 days. Procedure code 99214 billed 
on date of service June 1, 2022, which fell on the 90th day of the global value timeframe and rendered by the 
same provider is within the global surgery package of procedure 56620 billed on date of service March 3, 2022. 
Therefore, we decided that the Plan does not have to pay for the office services provided on June 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright/ high rise walker (E1399). 
 
You asked the Plan to pre-approve an upright/ high rise walker. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the requested item is not considered medically reasonable and 
necessary in this case. 
 
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 upright/ high rise walker. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found a two wheeled walker is the standard of care and more stable and potentially safer 
than a four wheeled walker. There is no clinical practice or evidence-based standards supporting the medical 
necessity of a four wheeled walker over a two wheeled walker. 
 
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 upright/ high rise walker have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an upright/ high rise walker (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enrollment in the Special Supplemental Benefits for the 
Chronically Ill (SSBCI) benefit. 
 
You asked the Plan to pre-approve SSBCI. You say that you would like to appeal this. The Plan denied your 
request. The Plan says the SSBCI attestation form was not received. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI have not been met. Specifically, the file does not support that the enrollee is at high risk for 
hospitalization, or require intensive care coordination. Therefore, we decided that the Plan does not have to pre-
approve enrollment in the Special Supplemental Benefits for the Chronically Ill (SSBCI) benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the enrollee is in Colorado doing work and has had 
some medical issues. The Plan denied your request. The Plan says the enrollee must receive care from a 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on June 24, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ureterolysis (50715-59-LT) provided on April 21, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is 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. Procedure code 50715-59-LT, a ureterolysis, 
with or without repositioning of ureter for retroperitoneal fibrosis is documented in the operative note 
submitted for review; however, this procedure is considered inclusive to CPT code 22558-62, a lumbar 
arthrodesis, using an anterior interbody technique, including minimal discectomy to prepare interspace (other 
than for decompression); therefore, the code cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for the ureterolysis (50715-59-LT) provided on April 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 19, 2022, to 
May 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
DRG is valid as billed. The Plan denied your request. The Plan says the diagnosis code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code G93.41, defined as metabolic encephalopathy. 
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 inpatient hospital services at the DRG 
originally billed. Our physician reviewer found that the enrollee presented to the emergency room for low back 
pain after a fall. The enrollee was afebrile. She had no acute focal neurologic deficits. There was no acute 
intracranial hemorrhage. In this case there was no clinical or laboratory evidence of metabolic encephalopathy. 
The records did not show that diagnosis code G93.41 was supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 19, 2022, to May 21, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 25, 2021, 
to September 29, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were reported correctly and are supported in the records provided. The Plan denied your request. The 
Plan says the reported DRG for this claim 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 inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with other gram-negative sepsis (A41.59) and acute 
kidney failure with tubular necrosis (N17.0). 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that these diagnoses are not 
supported in the medical record. Our physician reviewer found that the enrollees creatinine on admission was 
not 1.5x the value of 1.6, which is the criterion for determining the presence of acute renal failure in such an 
individual. In the absence of acute renal failure, the diagnosis of renal failure with acute tubular necrosis is 
deemed invalid. In particular there was nothing suggesting intrinsic injury to the kidneys with abnormalities of 
urine sodium excretion, nor was there cytological evidence of tubular injury such as muddy or granular casts; 
there was pyuria and bacteriuria consistent with a urinary tract infection (UTI). In addition, there was no 
clinical or laboratory evidence of sepsis or acute tubular necrosis. The review has determined that the medical 
records do not support the billing of other gram-negative sepsis (A41.59) and acute kidney failure with tubular 
necrosis (N17.0).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 25, 2021, to September 29, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device. 
 
You asked the Plan to pay for the TENS device. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the criteria for coverage have not been 
satisfied. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the documentation does not indicate the ordering provider discussed the ordered 
equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (TENS) device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept intraosseous basivertebral nerve ablation at 
L4-5. 
 
You asked the Plan to pre-approve Intracept. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for vertebrogenic low back pain, intervertebral disc degeneration, 
lumbar myofascial pain, spondylosis of the lumbar region, and lumbar radiculitis. The enrollee presented with 
low back pain rated at two out of ten and is radiating and aching. There is stiffness. The enrollee did not get 
much relief in her pain with the injection in January. The exam of the lumbar spine reveals bilateral paraspinal 
tenderness to palpation. There is bilateral gluteal musculature tenderness to palpation. The lumbar range of 
motion is grossly intact. Strength is five out of five in the bilateral lower extremities. Sensation is intact as are 
the deep tendon reflexes in the bilateral lower extremities. In this case, there were/are multiple plausible pathologic sources of significant pain generation. The radiating back pain, the noted pain-aggravating factors 
(activity), the intact spinal motion (in all directions), and the intact neurologic exam were/are all non-specific to 
any pathologic entities. Overall, the documentation is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Therefore, the enrollee does not meet criteria for the requested 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 Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Intracept intraosseous basivertebral nerve ablation at L4-5.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement (11044) provided on January 24, 2022.  
 
You asked the Plan to pay for the debridement. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do not support the code 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 11044 is Debridement, bone (includes epidermis, dermis, 
subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less. 
 
We find that CPT code 11044 is not supported in the medical record. Specifically, the procedure report does 
not include documentation of the tissue removed, such as subcutaneous tissue, muscle, or bone down to healthy 
bleeding tissue. Based on this information, we decided that Medicare rules for coverage of the debridement 
have not been met. Therefore, we decided that the Plan does not have to pay for a debridement (11044) 
provided on January 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that it is medically necessary for you to get continued 
care from the facility in order to get fully recovered. The Plan denied your request. The Plan says intermittent 
therapy or a restorative nursing program can be received on an outpatient basis in a residential setting, if 
needed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF care that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says that an intensive rehabilitation program is not medically necessary.
Our Medical director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that the documentation does not support that the complexity of the enrollee's nursing and medical needs required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.