Persius/hicric huggingface dataset:
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 is not medically 
necessary. 
 
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 based on the documentation provided, the enrollee has not had a significant change in 
her medical conditions that would require the intensity of rehabilitation physician oversight provided in the 
acute inpatient rehabilitation setting. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 23, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service April 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lymphedema therapy to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve lymphedema therapy. You say that you are retired and live on social 
security so you are unable to afford this procedure. The Plan denied your request. The Plan says services for 
your diagnosis can be provided by contracted, in-network providers. 
 
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 
lymphedema therapy to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a polysomnography (95811). 
 
You asked the Plan to pre-approve a polysomnography. The Plan denied your request. The Plan says that a 
facility-based sleep study is not needed since your OSA was confirmed in the past. 
 
The Plan follows Medicare rules. Medicare rules say that a type I polysomnography (PSG) is covered when 
used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if 
performed attended in a sleep lab facility.  
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 polysomnography. Our reviewer says 
that the criteria for coverage for a polysomnography have been met. Our physician reviewer found it is noted 
that you have previously been diagnosed with OSA. You are noted to have a CPAP unit which is broken 
beyond repair. The applicable LCD and NCD indicate that a type 1 sleep test (attended polysomnography) may 
be covered for use in performance of a CPAP titration (which is the applicable procedure in this case). Our 
reviewer also found that based on these factors, this request can be said to meet the requirements for 
authorization. 
 
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 polysomnography have been met. Therefore, we decided that the Plan has to 
pre-approve a polysomnography (95811).  
 
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 an office visit provided on December 13, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 December 13, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the DME provided on April 28, 2022, by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network DME. You say that the claim should be paid. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan. 
 
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 
the DME provided on April 28, 2022, by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health aide services provided from August 25, 2021, to 
August 27, 2021. 
 
You asked the Plan to pay for home health aide services. You say that you received conflicting information 
regarding the plan coverage. The Plan denied your request. The Plan says original Medicare is responsible for 
payment.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for home health aide services provided from August 25, 2021, to 
August 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CxBladder Monitor (0012M) provided on February 11, 
2022. 
 
You asked the Plan to pay for a CxBladder Monitor. You say that this test was medically necessary. The Plan 
denied your request. The Plan says per the Dex Diagnostic Exchange, the Cxbladder Monitor test is not 
covered by Medicare. The Plan also says that per the Centers of Medicare and Medicaid Services (CMS) 
guidelines, the Local Coverage Determination (LCD) 35396 noncoverage of code 0013M for Cxbladder was 
reaffirmed by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for 
procedure codes 0012M and 0013M for CxBladder.  
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CxBladder Monitor have not been met. Therefore, we decided that the Plan does not have to pay 
for a CxBladder Monitor (0012M) provided on February 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service February 10, 
2022. 
 
You asked the Plan to pay for procedure code 76942. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 76942 is bundled into 
payment for code 32554. 
 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 76942 
is a column II code to column I code 32554. 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 76942 billed for date of service February 10, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intermittent limb compression device (E0676) provided 
on February 16, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your 
contractual policy or by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for the treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the intermittent limb compression device (E0676) provided on February 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the T7-12 decompression and fusion with a left T9 
transpedicular decompression coded as 63046, 63048, 22610, 22614, 22842, 20930, 20936 and 63055. 
 
You asked the Plan to pre-approve the back surgery. You say that request reconsideration for the denied 
procedure. The enrollee has severe lumbar pain but the worst is in the mid back. Please see relevant clinicals 
for additional information. The Plan denied your request. The Plan says the enrollee did not meet the Medicare 
guidelines for the procedure, nor is the back spinal fusion surgery 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 the back surgery. 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 spinal stenosis of the thoracic region and 
intervertebral disc disorders with myelopathy of the thoracic region. However, detailed documentation is not 
evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care 
measures. The enrollee is noted to have had physical therapy; however, the therapy notes provided indicate 
treatment was for the foot.  Moreover, dynamic flexion/extension films are not provided in order to potentially assess the amount of movement (instability) at the requested surgical level. Detailed documentation is not 
evident regarding potential impending/inevitable temporary intra-operative instability. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested T7-12 decompression and fusion with a left T9 transpedicular 
decompression, in this case, is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the back surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the T7-12 decompression and fusion with a left T9 transpedicular decompression 
coded as 63046, 63048, 22610, 22614, 22842, 20930, 20936 and 63055.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CxBladder Monitor (0013M) provided on February 10, 
2022. 
 
You asked the Plan to pay for a CxBladder Monitor. You say that this test was medically necessary. The Plan 
denied your request. The Plan says per the Dex Diagnostic Exchange, the Cxbladder Monitor test is not 
covered by Medicare. The Plan also says that per the Centers of Medicare and Medicaid Services (CMS) 
guidelines, the Local Coverage Determination (LCD) 35396 noncoverage of code 0013M for Cxbladder was 
reaffirmed by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for 
procedure codes 0012M and 0013M for CxBladder.  
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CxBladder Monitor (0013M) have not been met. Therefore, we decided that the Plan does not 
have to pay for a CxBladder Monitor (0013M) provided on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) with an ophthalmologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the enrollee has been a patient for more than 10 
years. The Plan denied your request. The Plan says the medical care the enrollee requires can be provided by 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 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 
an office visit (99204) with an ophthalmologist to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric evaluation provided on February 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for psychiatric evaluation. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 psychiatric evaluation provided on February 3, 
2022, 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 September 15, 2021 billed 
with codes 81225, 81226, 81230, 81240, 81241, 81249, 81291, 81335, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. 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 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 
September 15, 2021 billed with codes 81225, 81226, 81230, 81240, 81241, 81249, 81291, 81335, and 81408.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve a SCS trial. 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 follows Medicare rules. Medicare rules say that a SCS trial is covered when specific criteria is 
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 SCS trial. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee does not have an evidence 
based indication for a SCS trial. The request is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.
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 IRF care is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has no rehabilitation needs that would need physical 
medicine and rehabilitation physician visits 3 times a week. The enrollee is not likely to improve with 3 hours a 
day for 5 days a week of treatment. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs identified or 
documented. At the current functional mobility, the enrollee does not need intensive therapies consisting of at 
least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. IRF 
admission is not medically necessary based lack of medical complexity and acute rehabilitation nursing needs. 
 
Documentation does not support the medical necessity for admission to an IRF. While the enrollee may benefit 
from continued physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely 
provided in a lower intensity and alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the over-the-counter (OTC) coronavirus test 
(U0003) purchased on February 11, 2022. 
 
You asked the Plan to reimburse you for the OTC test. You say that it was federally mandated that at-home 
coronavirus tests be covered. You say that there were no at-home tests available at the in network locations. 
You also say that you were advised to buy them where you could find them. The Plan denied your request. The 
Plan says the OTC coronavirus test kits are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the OTC 
test is an OTC item. Additionally, the record shows that the plan representative advised reimbursement was not guaranteed. Therefore, we decided that the Plan does not have to reimburse you for the over-the-counter (OTC) 
coronavirus test (U0003) purchased on February 11, 2022.