Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the pneumatic compression device provided from December 23, 2021, 
to January 18, 2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was treated for post-surgical 
lymphedema. The Plan denied your request. The Plan says that payment for this service is the responsibility of 
the facility. 
 
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 denied the services at issue as the payment is not made to any provider other than the facility for 
services furnished while an inpatient. However, the claim information shows that the services at issue were 
provided in the home setting. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the pneumatic compression device provided from December 23, 2021, to January 18, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95909 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 95909. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 95909 is bundled into payment for code 95861. 
 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 95909 
is a column II code to column I code 95861. 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 95909 billed for date of service March 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting 
of lumbosacral intervertebral disc degeneration with chronic low back pain have not been demonstrated in the 
peer-reviewed literature. 
 
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 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. More research is needed. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 64629).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 5, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70498. 
 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 70498. 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 August 5, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93010, & 93042 billed for date of service 
June 6, 2022. 
 You asked the Plan to pay for procedure codes 93010, & 93042. You say that the services were medically 
necessary. The Plan denied your request. The Plan says payment for codes 93010, & 93042 is bundled into 
payment for codes 36556, & 99291. 
 
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 codes 
93010, & 93042 are a column II code to column I codes 36556, & 99291. 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 93010, & 93042 billed 
for date of service June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for pain management. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network physicians available. 
 
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 out-of-network referral for pain management.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64490, & 64491 billed for date of service 
March 9, 2022. 
 You asked the Plan to pay for procedure codes 64490, & 64491. You say that the services were 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 codes 64490, & 64491 is 1. The MAI value for these codes is 2. You billed 2 
units each of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 64490, & 64491 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 64490, & 64491 billed for date of service March 9, 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 LTACH care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says 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 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 the enrollee appears to be improving but is still somewhat unstable and should 
only require short-term additional acute-care hospital services that can safely be provided at the current facility 
until more stable and 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies 
provided on January 20, 2022. 
 
You asked the Plan to pay for the CGM and supplies. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the CGM and supplies. Our reviewer says 
that the requested CGM and supplies are not medically reasonable and necessary in this case. Our physician 
reviewer found that the records do not indicate that insulin is administered multiple times daily to justify the 
need for a CGM. The records also do not document complicated diabetes. 
 
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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for the continuous glucose monitor (CGM) and supplies provided on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular/tissue-
based products for treating discogenic pain (code 0627T). 
 
You asked the Plan to pre-approve percutaneous injection of allogeneic cellular/tissue-based products. You say 
that percutaneous injection of allogeneic cellular/tissue-based products is medically necessary. The Plan denied 
your request. The Plan says percutaneous injection of allogeneic cellular/tissue-based products 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 percutaneous injection of allogeneic 
cellular/tissue-based products. Our reviewer says that the requested percutaneous injection of allogeneic 
cellular/tissue-based products is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that based on the medical records provided, review of the current peer-reviewed medical 
literature and the Medicare-approved major drug compendia (Drugdex/Micromedex) there is no documentation 
that the percutaneous injection of allogeneic cellular/tissue-based products at issue in this case meets all Medicare criteria for medically reasonable and necessary and safe and effective for the patient, per Social 
Security Act, Section 1862(a)1(A). The current peer-reviewed medical literature and the Medicare-approved 
major drug compendia do not support the use of allogeneic cellular/tissue-based injections as a safe and 
effective and medically reasonable and necessary treatment (with a long-term benefit on health outcomes) for 
persistent thoracic and lumbar back pain with diagnoses of facet syndrome and lumbar disc degeneration.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous injection of allogeneic cellular/tissue-based products have not 
been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous injection of 
allogeneic cellular/tissue-based products for treating discogenic pain (code 0627T).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on June 12, 2022.  
You asked the Plan to pay for the emergency room services. You say that the emergency room visit should 
only be $90. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 for 
emergency room care. The rules say that Medicare Part B generally does not pay for drugs that are usually self-
administered by the patients who take them. 
 
You have been asked to pay $94.63 for the services at issue. A $90 copayment was correctly applied for the 
emergency room services. The remaining $4.63 was for self-administered drugs. These drugs are not covered 
by Medicare in the outpatient setting. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to pay for emergency room services provided on 
June 12, 2022.
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 the records provided support the need for SNF care. 
The Plan denied your request. The Plan says SNF care is not medically necessary. The Plan says that the 
enrollee's needs can be safely provided 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 the enrollee does not have documented skilled nursing needs.  The enrollee does not 
have documented skilled therapy needs.  The enrollee is ambulating 100 feet.  Daily skilled services are not 
shown to be required to establish a maintenance program or to prevent deterioration of the enrollees condition.  
The enrollees care needs can, as a practical matter, 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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins
when required (D2950) provided on February 18, 2022.
You asked the Plan to pay for the crown and core buildup. You say that you would like to be reimbursed for
these services. The Plan denied your request. The Plan says these procedures are not benefits under the dental
plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown
(D2740) and core buildup, including any pins when required (D2950) provided on February 18, 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 the enrollee needs LTACH care. The 
Plan denied your request. The Plan says LTACH care 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 that the enrollee appears to be more stable but requires short-term additional acute 
care hospital services that can safely be provided 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. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this 
time. Completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDX testing (0037U) provided on February 
2, 2022. 
 
You asked the Plan to pay for FoundationOne CDX testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange.  
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of FoundationOne CDX 
testing have not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDX 
testing (0037U) provided on February 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Romtech Portable Connect Device to be provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the device. You say that this would be very beneficial to your recovery and 
much more cost effective and efficient than traveling to a physical therapy facility for similar follow-up care 
after surgery. The Plan denied your request. The Plan says the specific device requested is considered 
investigational due to insufficient quality peer-reviewed evidence of an outcomes benefit with this device. The 
Plan states the supplier of the device is out-of-network for your Plan.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 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. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation did not clearly describe that you would not be able to ambulate or 
participate in physical therapy either at home or as outpatient in order to justify prolonged use of a pneumatic 
compression device which does not replace genuine physical therapy which is still preferred in this clinical 
situation. Therefore, this pneumatic compression device will be considered not medically necessary. 
Furthermore, the requested provider in this case is not a network provider with the 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Romtech Portable Connect Device to be provided by an out-of-network provider.
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 it would be dangerous for the enrollee to return 
home without SNF care. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
criteria for admission to a SNF. 
 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 that the enrollee does not have documented skilled nursing needs. The enrollee does 
not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs can, as a 
practical matter, 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 skilled nursing facility (SNF) care.