Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has continued to decline since their 
discharge from the hospital. The Plan denied your request. The Plan says the services the enrollee needs can be 
provided safely in other settings, for example, a skilled nursing facility, home with home health services or 
home with outpatient therapy. 
 
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 there is not a reasonable expectation that this enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CGM and supplies. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
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. There is no record of use of insulin or frequent changes in 
medications. Based on this information, we decided that Medicare rules for coverage of the CGM have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the CGM and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 10, 2021 billed with 
codes 81321, 81317, 81206, and 81191. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
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 
August 10, 2021 billed with codes 81321, 81317, 81206, and 81191.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization. You say that the enrollee is suffering from chest 
pain, dizziness, and shortness of breath. You say that the requested procedure is needed to alleviate the 
enrollee's pain. You say that the enrollee is having sharp pains on the right side of her chest and her symptoms 
have worsened over the last two weeks. The Plan denied your request. The Plan says left heart catheterization 
is not medically necessary at this time. 
 
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 left heart catheterization. Our reviewer 
says that left heart catheterization is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has had two previous cardiac catheterizations, with no significant 
coronary artery disease found. The medical records provided do not support the rationale for this invasive 
imaging study. Guidelines do not support a need for cardiac catheterization in this 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 left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee remains in a hospital setting and will not 
get the proper care needed. The Plan denied your request. The Plan says the stay is not medically necessary 
based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is not a reasonable expectation that this enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve a CardioMEMS system. You say that the enrollee needs the requested 
device for treatment of his worsening heart failure. You say that the requested implant is medically necessary 
and supported by the medical records provided. The Plan denied your request. The Plan says there are not 
enough studies to show that the requested device is better than other kinds of treatment for the enrollee's 
problem. The Plan says that the CardioMEMS system may be covered if it is used for care in a Medicare-
approved medical research study. 
 
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 a CardioMEMS system. Our reviewer 
says that a CardioMEMS system is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the requested injections. You say that you feel that this is needed to help 
with your pain. The Plan denied your request. The Plan says LCD criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections may be covered only when 
certain criteria, described in the Medicare rules section of this decision, are met.  
 
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 requested injections. Our reviewer 
says that the requested injections are not shown to be reasonable and necessary based on the LCD guidelines. 
Our physician reviewer found the enrollee has chronic low back pain. He has constant low back pain that radiates to the lateral portion of the right thigh. He reports that both of his feet are numb. The pain is 
aggravated by activity.  He is status post L2-L5 fusion. He has been treated with medical therapy, physical 
therapy, and epidural steroid injections. His provider has recommended lumbar facet injections. 
 
As there is documented radiculopathy, the criteria for facet joint injections are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services billed for date of service October 26, 
2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says there is 
insufficient documentation to corroborate the services. 
 
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 J0585 is injection, onabotulinumtoxina, 1 unit. The 
definition of code 95870 is needle electromyography; limited study of muscles in 1 extremity or non-limb 
(axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or 
sphincters. The definition of code 64612 is chemodenervation of muscle(s); muscle(s) innervated by facial 
nerve, unilateral (eg, for blepharospasm, hemifacial spasm).  
 
 We find that CPT codes J0585, 95870, 64612 are not supported in the medical record. The records provided do 
not sufficiently show that the services at issue were billed. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for the injection services billed for date of service October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve the SI joint injection. You say that it is felt that this injection would be 
appropriate in this case. The Plan denied your request. The Plan says a sacroiliac joint injection does not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that SI joint injections can be considered positive and 
reasonable and necessary when they produce 75%-100% pain relief.  
 
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 SI joint injection. Our reviewer says 
that the requested injection is not considered reasonable and necessary in this case. Our physician reviewer 
found the notes reveal that the enrollee received an initial SI joint injection on June 28, 2021, that improved her 
pain by 35% and that she was able to move 50% more easily than prior to the injection. The review has determined that the requested repeat sacroiliac joint injection does not meet the Medicare coverage criteria. 
 
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 SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on October 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic testing/monitoring services (95861, 95938, 
95940) provided on December 8, 2021. 
 
You asked the Plan to pay for diagnostic testing/monitoring. You say that these services were pre-approved and 
should be paid to the provider directly. The Plan denied your request. The Plan says the payment for these 
technical component services is included in the facility payment. The provider should bill the facility. In addition, when services are provided in a mobile unit, they are generally provided to serve an entity for with 
another Place of Service (POS) code exists. If the mobile unit is service an entity, such as an outpatient hospital 
facility, for which another POS code already exists, providers should use the POS code for that entity rather 
than POS code 15 for a mobile unit. 
 
The Plan must follow Medicare rules. Medicare rules say that A/B MACs (B) may not pay for the technical 
component (TC) of radiology services furnished to hospital patients. Payment for physicians radiological 
services to the hospital, e.g., administrative or supervisory services, and for provider services needed to 
produce the radiology service, is made by the AB MAC (A) to the hospital as a provider service. The rules also 
say that if a mobile unit is serving an entity for which a POS code exists, the provider should use the POS code 
for that entity. 
 
We looked at the file and Medicare rules. The records show that the services at issue include the technical 
components and were provided to an enrollee in an outpatient hospital setting. This means that the payment for 
these services is included in the payment to the hospital facility, and the appropriate POS code for this claim is 
the outpatient hospital facility code. Based on this information, we decided that Medicare rules for coverage of 
diagnostic testing/monitoring have not been met. Therefore, we decided that the Plan does not have to pay for 
diagnostic testing/monitoring services (95861, 95938, 95940) provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA disc matrix injection procedure. 
 
You asked the Plan to pre-approve the VIA disc matrix injection procedure. You say that this procedure is 
medically necessary for your condition. The Plan denied your request. The Plan says this is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the VIA disc matrix injection 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that you have a history of chronic low back pain due to 
lumbar intervertebral disc degeneration. You have had both midline and paramidline pain with coughing, 
sneezing, bowel movements, and sitting intolerance with an average reported pain level of 7/10. You have also 
failed conservative treatment injections, therapy, exercises, and pain medications. In this case, there is little 
evidence in the medical literature to suggest that this procedure is appropriate for your back pain. It is not an 
accepted standard of medical practice for the diagnosis or treatment of back pain. The guidelines state that 
agents such as platelet-rich plasma, amniotic fluid, gabapentin, and others have been investigated, but there is not sufficient evidence to support use and they are considered investigational. The requested procedure is 
considered investigational and not medically necessary for the treatment of degenerative disc disease. 
 
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 VIA disc matrix injection procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the VIA disc matrix injection procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urinalysis provided on January 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for urinalysis. You say that you would like to appeal the denial of the 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 urinalysis provided on January 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic testing/monitoring services (95939, 95938, 95869, 
95970, 95940) provided on December 14, 2021. 
 
You asked the Plan to pay for diagnostic testing/monitoring. You say that these services were pre-approved and 
should be paid to the provider directly. The Plan denied your request. The Plan says the payment for these 
technical component services is included in the facility payment. The provider should bill the facility. In addition, when services are provided in a mobile unit, they are generally provided to serve an entity for with 
another Place of Service (POS) code exists. If the mobile unit is service an entity, such as an outpatient hospital 
facility, for which another POS code already exists, providers should use the POS code for that entity rather 
than POS code 15 for a mobile unit. 
 
The Plan must follow Medicare rules. Medicare rules say that A/B MACs (B) may not pay for the technical 
component (TC) of radiology services furnished to hospital patients. Payment for physicians radiological 
services to the hospital, e.g., administrative or supervisory services, and for provider services needed to 
produce the radiology service, is made by the AB MAC (A) to the hospital as a provider service. The rules also 
say that if a mobile unit is serving an entity for which a POS code exists, the provider should use the POS code 
for that entity. 
 
We looked at the file and Medicare rules. The records show that the services at issue include the technical 
components and were provided to an enrollee in an outpatient hospital setting. This means that the payment for 
these services is included in the payment to the hospital facility. In addition, this claim was billed with an 
incorrect POS code as the appropriate POS code for this claim would be the POS code for an outpatient 
hospital facility. Based on this information, we decided that Medicare rules for coverage of diagnostic 
testing/monitoring have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic 
testing/monitoring services (95939, 95938, 95869, 95970, 95940) provided on December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 18, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
in the home health or hospice setting, each 15 minutes (CPT code G0299). 
 
You asked the Plan to pre-approve the services. You say that you are in need of rehabilitation and need to 
strengthen your leg and knees. The Plan denied your request. The Plan says your request is not medically 
necessary because your records do not show that you are under the care of a physician or other allowed 
practitioner who has developed and certified a plan of care. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our physician reviewer 
found your medical needs are stable and the planned and provided skilled nursing services are duplicative of 
the rehabilitation services and 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve direct skilled nursing services of a registered nurse (RN) in the home health or hospice 
setting, each 15 minutes (CPT code G0299).