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

 
We decided that the Plan does not have to pre-approve a vertiflex procedure. 
 
You asked the Plan to pre-approve a vertiflex 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 a vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertilfex 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 a vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intravenous infusion and laboratory services (96367, 
81003, 85025, 85652) provided on January 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the intravenous infusion and laboratory services. You say that the services should 
be covered as they were medically necessary. The Plan denied your request. The Plan says the enrollee must 
receive services in-network and there is no record of prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an intravenous infusion and laboratory services 
(96367, 81003, 85025, 85652) provided on January 22, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
January 17, 2022. 
 
You asked the Plan to pay for out of network services. . You say that this claim should be paid. The Plan 
denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 out of network physician services provided to the 
enrollee on January 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on February 10, 
2022. 
 
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 the policy only covers non-emergency ambulance transportation when it is the only way to safely 
and adequately transport a member, or if other means of transport are unsafe due to a medical condition. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 not medically reasonable or necessary. Our physician reviewer found transportation via 
ambulance from the hospital to the enrollees residential facility was not medically necessary. The enrollee did 
not require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport. Transportation could have been provided by other means (stretcher van, wheelchair 
van) without endangering the enrollees condition. 
 
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 pay for ambulance services provided to the enrollee on February 10, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on July 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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 has not provided sufficient evidence to support the reasoning for the 
denial of payment based on Medicare criteria. Therefore, we decided that the Plan has to pay for the laboratory 
services provided on July 28, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on 
December 11, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network services provided to the enrollee on 
December 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation 
(93293) provided on August 17, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the transtelephonic rhythm strip pacemaker evaluation. You say that the services 
were medically necessary. The Plan denied your request. The Plan says the services denied correctly as there 
were not emergent and care could have been provided in-network. 
 
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 the transtelephonic rhythm strip pacemaker 
evaluation (93293) provided on August 17, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs are limited to a maximum of four (4) sessions 
per spinal region in a rolling twelve (12) month period. 
 
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 epidural steroid injections. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, you 
have received five (5) lumbar epidural steroid injections over the past twelve (12) months. The review has 
determined that you do not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint fusion surgery 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no trial of physical therapy. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there has been no recent trial of physical therapy for back pain. More conservative measures are 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint fusion surgery
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fecal occult blood screening testing provided on March 10, 
2022. 
 
You asked the Plan to pay for fecal occult blood test. You say that your doctor wanted this test performed 
again. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
this test is covered once every 12 months and you previously received it on February 1, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that a fecal-occult blood test is covered once every 12 
months.  
 
We looked at the file and Medicare rules. You had a covered fecal-occult blood test less than 12 months prior 
to this testing. Based on this information, we decided that Medicare rules for coverage of fecal occult blood test 
have not been met. Therefore, we decided that the Plan does not have to pay for fecal occult blood screening 
testing provided on March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and associated procedures to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and associated procedures. You say that the requested 
provider is the only wound care provider in the area. The enrollee has a wound that needs to be treated before 
he has to be hospitalized due to having an open wound. The Plan denied your request. The Plan says the 
enrollee cannot self-direct care to a non-participating provider. This service is available by a provider in your 
network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit and associated procedures to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (0037U) provided on December 21, 2021. 
 
You asked the Plan to pay for code 0037U. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. The gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing (0037U) provided on December 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visits provided on January 11, 2022, to 
February 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy visits. You say that the provider was in the same health care 
group as your primary care provider. The Plan denied your request. The Plan says the services were provided 
out-of-network and not approved in advance. 
 
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 the psychotherapy visits provided on January 11, 
2022, to February 15, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 12, 
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 this was not reported 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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 pay 
for laboratory services provided to the enrollee on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an echocardiography, transthoracic, real-time with 
image documentation (2D), includes M-mode recording (93351). 
 
You asked the Plan to pre-approve an echocardiography, transthoracic, real-time with image documentation 
(2D), includes M-mode recording. You say that an echocardiography, transthoracic, real-time with image 
documentation (2D), includes M-mode recording is medically necessary. The Plan denied your request. The 
Plan says an echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode 
recording does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 echocardiography, transthoracic, 
real-time with image documentation (2D), includes M-mode recording. Our reviewer says that an 
echocardiography, transthoracic, real-time with image documentation (2D) is not medically necessary. Our 
physician reviewer found at issue is the medical appropriateness and necessity of carrying out a stress 
echocardiogram in this asymptomatic patient whose abnormal ECG is unchanged from that of 2017, at which 
time a stress echocardiogram was performed and found to be normal. There is no evidence provided that would 
support the need for stress echocardiography. In summary, there is insufficient documentation to support the 
medical necessity for the requested stress echocardiography in this patients clinical 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 an echocardiography, transthoracic, real-time with image documentation (2D), 
includes M-mode recording have not been met. Therefore, we decided that the Plan does not have to pre-
approve an echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode 
recording (93351).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Resperate device purchased on October 25, 2021. 
 
You asked the Plan to pay for this device. You say that this device is medically necessary for your use. The 
Plan denied your request. The Plan says this device is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare does not cover precautionary devices. This item is 
precautionary and is available to the general public. This item would be helpful even to those who are not sick 
or injured. Therefore, we decided that the Plan does not have to pay for a Resperate device purchased on 
October 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on February 2, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says out-of-network services are excluded from coverage. 
 
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 radiology services provided to the enrollee on 
February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99214) provided to the 
enrollee on October 18, 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 there was not a non-evaluation and management service billed the same rendering provider on 
the same day. 
 
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 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires at least 2 of these 3 key components: A 
detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting 
problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient 
and/or family." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the attached documentation does not the support of evaluation and management code 99214-25. The servicing provider and billing provider 
would not be appropriate, as there was no signature or attestation by the provider on the attached evaluation 
and management. Also, the documentation include anything of the enrollee's current status. It seems as if the 
enrollee was only in office for the administration of chemotherapy by the registered nurse. 
 
We looked at this coder'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 pay for an office visit (procedure code 99214) provided to the enrollee on October 18, 2021.