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

 
We decided that the Plan has to pay for the supplies related to a transcutaneous electrical nerve stimulator 
(TENS) provided on June 9, 2022. 
 
You asked the Plan to pay for the TENS supplies. You say that these supplies are for use with a medically 
necessary TENS unit which was ordered by the treating physician. The Plan denied your request. The Plan says 
that this cannot be covered because the physician states he did not order these items. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan's denial rationale is directly refuted by the manually signed order form, 
as well as the contemporaneous progress note in which the order of the TENS is clearly documented. The fact 
that an office representative stated on a phone call that this was not ordered is insufficient to refute the evidence 
in the file. The file also includes a delivery ticket and delivery confirmation. We find no deficiency which 
would support the denial of the billed items. Therefore, we decided that the Plan has to pay for the supplies 
related to a transcutaneous electrical nerve stimulator (TENS) provided on June 9, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care continued stay. 
 
You asked the Plan to pre-approve SNF care. You say that you would benefit from skilled nursing services 
continued stay due to your medical complexity. The Plan denied your request. The Plan says your needs can be 
met at a lower level of care. 
 
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 continued stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee was recently hospitalized with a COPD exacerbation. The enrollee improved on BiPAP. The 
enrollee may benefit from BiPAP with average volume assured pressure support (AVAPS) during 
sleep. However, Medicare does not cover a home ventilator when used as BiPAP. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria for SNF admission has not been met. 
 
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 the enrollee does not have documented skilled nursing or skilled therapy needs. Daily 
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 
the enrollee's condition. The enrollee's care needs can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical bone growth stimulator (E0748) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an electrical bone growth stimulator. You say that the requested item is a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for OON services 
have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an electrical bone growth stimulator (E0748) to be provided by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided April 11, 2022, to May 10, 
2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says a valid NOA was not submitted for the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for all beneficiaries receiving Home Health 
services in 2021 whose services will continue in 2022, the Home Health Agency (HHA) shall submit an Notice 
of Admission (NOA) with a one-time, artificial 'admission' date corresponding to the "From" date of the first 
period of continuing care in 2022. 
 
We looked at the file and Medicare rules. The NOA submitted had a from date of October 13, 2021, and not the 
date corresponding to the first "from" date in 2022. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have 
to pay for home health services provided April 11, 2022, to May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic cardiovascular testing (81161, 81404, 81407, and 
81408) provided on June 2, 2021. 
 
You asked the Plan to pay for genetic cardiovascular testing. You say that this testing was necessary and should 
be paid. 
 The Plan denied your request. The Plan says this service does not qualify as a covered cardiovascular disease 
screening and was not medically necessary. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The rules say that a cardiovascular disease screening 
(blood) test is defined as a lipid panel consisting of a total cholesterol, high-density lipoprotein (HDL) 
cholesterol and triglyceride. 
 
The test at issue in this appeal, genetic cardiovascular testing, does not qualify as a cardiovascular disease 
screening test as defined by Medicare. The records indicate that the enrollee has no personal history of 
cardiovascular disease, and the records indicate via checkbox that the clinical management of this enrollee will 
not be affected by the results of this test. Medicare does not cover genetic cardiovascular testing solely for 
screening purposes. Therefore, we decided that the Plan does not have to pay for genetic cardiovascular testing 
(81161, 81404, 81407, and 81408) provided on June 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for SNF care is correct. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 85060 and G0452 provided on May 2, 2022. 
 
You asked the Plan to pay for codes 85060 and G0452. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 85060 and G0452 are not supported in the medical record. Specifically, code 85060 
has a Physician Fee Schedule Payment Policy Indicator File Record Layout, indicator "8" states This indicator 
identifies the professional component of clinical laboratory codes for which separate payment may be made 
only if the physician interprets an abnormal smear for hospital inpatient. This applies only to code 85060. No 
technical component billing is recognized because payment for the underlying clinical laboratory test is made 
to the hospital, generally through the PPS rate. No payment is recognized for code 85060 furnished to hospital 
outpatients or non-hospital patients. This code was billed with place of service 81 (independent laboratory). 
This place of service is inappropriate to bill with professional services. Code G0452 should not be reported 
without modifier 26 (Professional Component) because it is an interpretation and report only service. This 
service was therefore, not billed with the appropriate modifier. 
 
Based on this information, we decided that Medicare rules for coverage of codes 85060 and G0452 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 85060 and G0452 provided on 
May 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi (J9713). 
 
You asked the Plan to pre-approve Imfinzi. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is not medically reasonable or 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Imfinzi. Our reviewer says that the 
requested drug, Imfinzi, is not medically necessary. Our physician reviewer found the records provided do not 
indicate the PDL-1 or mutational status of the tumor. The Food and Drug Administration has not stated that the 
requested drug is indicated in the combination prescribed for the enrollee's condition. The Medicare approved 
cancer drug compendia do not contain a supportive citation for the use of the requested drug in the combination 
prescribed in the enrollee's clinical situation. Therefore, the reviewer found that the requested drug is not 
medically necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi (J9713).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 21, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this service was medically necessary. 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 August 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 20, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
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 appears to still be unstable and requires short-term additional acute care 
hospital services that can be safely administered at the current facility until more stable for transfer or 
discharge. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36010 and 75743 billed for date of service 
March 24, 2022. 
 
You asked the Plan to pay for procedure codes 36010 and 75743.. The Plan denied your request. The Plan says 
payment for code 36010 is bundled into payment for code 36015.  
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 36010 
is a column II code to column I code 36015. We have also confirmed that code 75743 is a column II code to 
column I code 37184. 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 codes 36010 and 75743 billed for date of service March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the provided records document that the home ventilator is being requested for use in average volume 
assured pressure support (AVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device 
with AVAPS and a back-up rate. Medicare does not provide coverage for ventilators used to provide BiPAP 
therapy.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the right L5-S3 facet 
joints and RFA of the sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve RFA of the right L5-S3 facet joints and RFA of the sacroiliac (SI) joint. 
You say that the requested RFA of the right L5-S3 facet joints and RFA of the sacroiliac (SI) joint are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve RFA of the right L5-S3 facet joints and 
RFA of the sacroiliac (SI) joint. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found this is considered an 
experimental/investigational procedure because of the wide variation in efficacy as reported in the literature. 
Therefore, the request is deemed not medically reasonable and necessary. 
 
Furthermore, RFA of the SI joint is specifically not covered by Medicare. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the right L5-S3 facet joints and RFA of the sacroiliac (SI) joint have not 
been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of 
the right L5-S3 facet joints and RFA of the sacroiliac (SI) joint.