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

 
We decided that the Plan does not have to pay for a pharmacogenetic panel (81240, 81241, 81291, 81335) 
provided on November 18, 2021. 
 
You asked the Plan to pay for a pharmacogenetic panel. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not billed correctly. 
 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 81240, 81241, 81291, and 81335 are not supported in the medical record. Specifically, 
these codes were used to report a panel, which should be billed as one service. Based on this information, we 
decided that Medicare rules for coverage of a pharmacogenetic panel have not been met. Therefore, we decided 
that the Plan does not have to pay for a pharmacogenetic panel (81240, 81241, 81291, 81335) provided on 
November 18, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on December 5, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says the claim is a suspected duplicate. 
 
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 looked at the file and the rules. In this case, there are insufficient medical records to show that the 
evaluation service was provided for an unrelated problem. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency room services provided on December 5, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an interval injection provided to the enrollee on November 1, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denial is appropriate given the clinical scenario. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure is part of pump maintenance of therapy. The procedure is medically reasonable and 
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 services have been met. Therefore, we decided that the Plan has to pay for 
an interval injection provided to the enrollee on November 1, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 sensor. 
 
You asked the Plan to pre-approve Dexcom G6 sensor. You say that this will help you with your blood glucose 
count. The Plan denied your request. The Plan says that you are not on insulin at least three times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of Dexcom G6 
sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 
sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the greater and lesser 
occipital nerves. 
 
You asked the Plan to pre-approve occipital nerve RFA. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this 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 occipital nerve RFA. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental/investigational procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of occipital nerve RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA) of the greater and lesser occipital nerves.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm (J0172). 
 
You asked the Plan to pre-approve Aduhelm. You say that the enrollee has a LP with spinal fluids consistent 
with Alzheimer's. You also say that the requested drug is medically necessary. The Plan denied your request. 
The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Aduhelm. Our reviewer says that the 
requested drug, Aduhelm, is not medically necessary. Our physician reviewer found the provided 
documentation does not support that Aduhelm is medically reasonable and necessary for the enrollee in this 
case. The magnetic resonance imaging (MRI) suggests a mixed etiology for the enrollee's symptoms. The 
reviewer found that it has not been shown that Aduhelm (Aducanumab) is at least as beneficial as existing and 
appropriate and available medically appropriate alternatives for this enrollee. Additionally, the reviewer found 
that the provided documentation does not support that Aduhelm is reasonably expected to be safe and effective 
for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aduhelm (J0172).
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says LTACH services are not medically necessary and your 
recent performance in therapy and your activities of daily living and mobility, demonstrate your care needs can 
be met in an alternate setting, such as a skilled nursing facility or with home health care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you should be able to be safely treated at a lower level of care when treatment 
has been completed. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953), and tooth extractions 
(D7210) provided by a participating provider on November 22, 2021. 
 
You asked the Plan to pay for a bone replacement graft and tooth extractions. You say that you did not have 
any services provided in 2021. You say that you believe that this should be covered. The Plan denied your 
request. The Plan says D7953 is not a covered dental benefit. The Plan says that the benefit limit for D7210 has 
been met and exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan one tooth extraction 
per year. The Plan does not cover D7953. 
 
We looked at the file and Medicare rules. 5 extractions were provided on the date of service in question; therefore, the benefit limit for D7210 has been met and exhausted. D7953 is not a covered dental benefit. Based 
on this information, we decided that the Plan's rules for coverage for tooth extractions have not been met. 
Therefore, we decided that the Plan does not have to pay for a bone replacement graft (D7953), and tooth 
extractions (D7210) provided by a participating provider on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-waterproof tape, (A4450) and moderate sedation 
services (99156 and 99157) provided on April 7, 2021. 
  You asked the Plan to pay for the non-waterproof tape, (A4450) and moderate sedation services (99156 and 
99157). You say that the services were performed in good faith that the codes would be paid appropriately. 
You say that the records should be reviewed, and the claim processed for payment. The Plan denied your 
request. The Plan says procedure codes 27096, J0702, J2250, J3010 have been overturned and CPT code 
A4450 cannot be paid under the physician fee schedule. The Plan also says that a modifier cannot be billed 
with CPT codes 99156 and 99157 to bypass the code edit. 
 
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 99156 
and 99157 are column II codes to column I code 27096. This claim cannot be billed with a modifier to bypass 
the edit. In addition, payment for CPT code A4450 cannot be issued under the physician fee schedule. Based on 
the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not 
have to pay for the non-waterproof tape, (A4450) and moderate sedation services (99156 and 99157) provided 
on April 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 13, 
2021, to February 17, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the inpatient hospital stay was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found at the time of admission, as no other severe condition was identified, it was not 
expected that the enrollee would require hospital services that would likely cross 2 midnights as there was no 
signs of sepsis and they were responding to initial treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from February 13, 2021, to February 
17, 2021.
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 LTACH services. You say that LTACH care is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical necessity rules for LTACH care have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be completed at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on August 28, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that at the time you called, this was an 
emergency situation. You say that you were not aware that there were differences in the ambulances that 
arrived. You also say that only once ambulance arrived and they brought you to the emergency room. The Plan 
denied your request. The Plan says since there was no transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 28, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on August 28, 2021.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found while the patient has a need for physical or occupational therapy, there is no 
documentation of a need for an intensive inpatient rehabilitation program.  
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: 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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available and being provided at the health care setting being offered by the health plan. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an over-bed table provided on December 3, 2021. 
 
You asked the Plan to pay for an over-bed table. You say that the same item was approved for a person known 
to you. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that an over-bed table is not covered because it is not 
primarily medical in nature.  
 
While an over-bed table may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for an over-bed table provided on December 3, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance and localization of needle or catheter 
tip (77003) provided on November 16, 2021. 
 
You asked the Plan to pay for fluoroscopic guidance. You say that this service is supported in the record. The 
Plan denied your request. The Plan says this is an add-on code that cannot be billed without an appropriate 
primary procedure code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. CMS 
identifies Add-on Codes (AOC) and their primary codes based on CPT manual instructions, CMS interpretation 
of HCPCS/CPT codes, and CMS coding instructions. The Type I AOC Edit Table lists AOCs for which the 
CPT Manual or HCPCS tables define all acceptable primary codes. Claims processing contractors should not 
allow other primary codes with Type I AOCs. 
 
We find that CPT code 77003 is not supported in the medical record. Specifically, this service is listed on the 
Type I AOC Edit Table as an add-on code and was not billed with an appropriate Primary Procedure as 
indicated by Medicare guidelines. Based on this information, we decided that Medicare rules for coverage of 
fluoroscopic guidance have not been met. Therefore, we decided that the Plan does not have to pay for 
fluoroscopic guidance and localization of needle or catheter tip (77003) provided on November 16, 2021.