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

 
We decided that the Plan has to pay for the tempus tumor origin test (CPT code 81479). 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says that the requested service, Tempus TO, does not have FDA approval. 
 
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 service. Our physician reviewer found 
the review has determined that the requested the tempus tumor origin test (CPT code 81479) is medically 
necessary and reasonable. 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 service have been met. Therefore, we decided 
that the Plan has to pay for the tempus tumor origin test (CPT code 81479).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a regular gastric emptying study provided on 
October 26, 2020. 
 
You asked the Plan to pay for a regular gastric emptying study. You say that you started a new computer 
system on October 23, 2020, and certain procedure codes were not put in the system for you to bill. The Plan 
denied your request. The Plan says the claim was untimely and the submission did not meet the exception 
criteria guidelines outlined in Medicare. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for a regular gastric emptying study was not filed until December 10, 2021. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for a regular gastric emptying study provided on 
October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genicular nerve radiofrequency ablation procedure (CPT 
code 64624) provided on November 23, 2021. 
 
You asked the Plan to pay for the service. You say that the services were necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of a genicular nerve radiofrequency ablation in the 
setting of osteoarthritis of the knee have not been demonstrated in the peer-reviewed literature. 
 
 
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 service. Our physician reviewer found 
per a review of medical literature genicular nerve block and genicular nerve ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the genicular nerve block is not 
reasonable or 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for genicular nerve radiofrequency ablation procedure (CPT code 64624) provided on November 
23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided on September 20, 2021, 
by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a 
network provider, and the services were not urgent or emergent, nor were they 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 skilled nursing services provided on 
September 20, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, power seat elevation 
system, and electronic connection between wheelchair controller and 2 or more power seating system motors. 
 
You asked the Plan to pre-approve an expandable controller, harness, power seat elevation system, and 
electronic connection between wheelchair controller and 2 or more power seating system motors. You say that 
the items 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 wheelchair accessories are covered when specific 
criteria 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 an expandable controller, harness, 
power seat elevation system, and electronic connection between wheelchair controller and 2 or more power 
seating system motors. Our reviewer says that the items are not medically necessary. Our physician reviewer 
found the expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) 
and other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin 
control, head control, etc.) are not medically necessary per Local Coverage Article: Wheelchair 
Options/Accessories - Policy Article (A52504). You do not require non-proportional input devices (e.g., sip 
and puff, head array, etc.). You do not require a separate display (i.e., for alternate control devices), other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. You have 3 power options of tilt, recline, and power elevating leg rests but 
you do not need to control the power options through a joystick. Your upper extremity strength and function 
support that you can control any power options through their own switches. 
 
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 expandable controller, harness, power seat elevation system, and electronic 
connection between wheelchair controller and 2 or more power seating system motors have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, power seat elevation system, and electronic connection between wheelchair controller and 2 or more power seating system 
motors.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from July 13, 2019, through 
July 17, 2019. 
 
You asked the Plan to pay for inpatient hospital care. You say that you submitted supporting documentation for 
reconsideration. The Plan denied your request. The Plan says payment of DRG 871 remains not supported.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 inpatient hospital care. Our physician reviewer found the review has determined 
that DRG 871 was not supported by the records provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital care provided from July 13, 2019, through July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power group 3 standard wheelchair (K0861). 
 
You asked the Plan to pre-approve a power group 3 standard wheelchair. You say that your current chair is 7 
years old and has over 3k miles on it. You say that you are homeless, and you need a new chair as you are in 
your chair a lot. You relocate frequently and it affects your daily living not having a good POV. The Plan 
denied your request. The Plan says after a new evaluation, you were approved for a group 4 power wheelchair 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you cannot safely operate the PMD being requested. The file also shows that you have been 
approved for a group 4 PWC with multipower option. This means that Medicare rules for coverage of a PMD 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a power group 3 standard 
wheelchair (K0861).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is walking 
household distances with a rolling walker with stand-by assistance and was contact guard assist for transfers. 
Provided records do not document a significant decline in the enrollees functional status to necessitate further 
daily inpatient skilled therapy services. The enrollee does not require the services on an inpatient basis, only in 
a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a 
part time basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (CPT code S9500) provided from 
June 19, 2021, through June 28, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code S9500, which has an assigned status code I equals not valid for Medicare purposes. Medicare uses 
another code for reporting of and payment for these services. 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 the home infusion therapy (CPT code S9500) provided from June 19, 2021, through June 28, 
2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2. You say that the item is necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has 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. 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 a FreeStyle 
Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 
2.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture treatment provided on July 26, 2021, and  
July 29, 2021. 
 
You asked the Plan to pay for acupuncture treatment. The Plan denied your request. The Plan says the provider 
is not a legally qualified physician. This provider is not supervised by a physician, PA, or NP/CNS. 
 
The Plan must follow Medicare rules. The rules say that these treatments may be provided by a physician in 
accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse specialists, and 
auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing acupuncture 
must be under the appropriate level of supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist. 
 
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 acupuncture treatment. Our reviewer 
says that the acupuncture treatment does not meet the Medicare coverage criteria. Our physician reviewer 
found that the services were rendered by a non-covered provider type, a licensed acupuncturist, not a physician. 
The provider is not a legally qualified physician. This provider is not supervised by a physician, PA, or 
NP/CNS. This denial is based upon a non-covered provider type-a licensed acupuncturist, not a physician. The 
review has determined that the acupuncture treatment at issue in this appeal did 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 acupuncture treatment have not been met. Therefore, we decided that the Plan 
does not have to pay for acupuncture treatment provided on July 26, 2021, and July 29, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The enrollee has no acute medical problems, is medically stable and does not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical. The enrollee does not need intensive therapies, consisting of 
at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in 
an IRF. At the current level of function, the enrollee's rehab can be safely provided at a lower intensity and 
alternate setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
IRF 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 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code G0482) provided on July 9, 
2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code G0482 90 (1 
Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11; therefore, the billed code cannot be verified. It is 
noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided 
that the Plan does not have to pay for the laboratory service (CPT code G0482) provided on July 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre. 
 
You asked the Plan to pre-approve Freestyle Libre. You say that the item is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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. 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 Freestyle 
Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and treatment for dental services to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a consultation and treatment for dental services. You say that there are no 
in-network endodontists within 50 miles of where you live. The Plan denied your request. The Plan says the 
documentation indicates that your needs can be met in-network therefore, going out of network is not medically 
necessary at this time. There are 3 in-network providers within a 50-mile radius of your zip code. 
 
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 
a consultation and treatment for dental services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab service provided on August 31, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says this code is 
ineligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 In this case, the CPT Code Manual definition of code 83789 is Mass spectrometry and tandem mass 
spectrometry (e.g., MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. We find that CPT code 83789 is not supported in the medical record. 
Validity testing on urine specimens used for drug testing shall not be separately billed. 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 lab service provided on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for simple repair of superficial wounds (CPT code 12011) 
provided on September 4, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 12011 
is a column II code to column I code 26720. 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 simple repair of superficial wounds (CPT code 12011) provided 
on September 4, 2021.