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

 
We decided that the Plan does not have to pre-approve Freestyle lite Test Strips. 
 
You asked the Plan to pre-approve Freestyle lite Test Strips. The Plan denied your request. The Plan says they 
have 2 preferred vendors for these requested items that can be used. The Plan says that your provider has now 
changed the type of test strips and monitor requested in the prescription. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may specify brands and manufacturers as 
preferred and may limit coverage to only those preferred brands and manufacturers as long as the enrollee 
retains access to all medically necessary items. 
 
We looked at the file and Medicare rules. The type of test strips being requested are from a non-preferred 
vendor. Based on this information, we decided that Medicare rules for coverage of Freestyle lite Test Strips 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle lite Test Strips.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on June 8, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration of the denied 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 outpatient mental health services provided on June 
8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for office visits provided from March 12, 2021, to 
December 10, 2021. 
 
You asked the Plan to reimburse you for office visits. The Plan denied your request. The Plan says an itemized 
bill is required and was not received in the allotted timeframe. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of office visits provided from 
March 12, 2021, to December 10, 2021 have been met. The Plan has not received an itemized bill. Therefore, 
we decided that the Plan does not have to reimburse you for office visits provided from March 12, 2021, to 
December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided the Plan does not have to pay for urine testing services provided to the enrollee on May 6, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan 
denied your request. The Plan says the test panel is a single test with multiple components and is characterized 
by a single unit of service (UOS =1). A panel cannot be unbundled and billed as individual components 
although the test reports multiple individual pathogens and/or targets. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed as the 
services were not listed appropriately. The codes submitted on the claim cannot be paid separately. Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for urine testing services provided to the enrollee on May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve block (64418 x 2) and imaging 
guidance (76942). 
 
You asked the Plan to pre-approve the injections. You say that you need this nerve block to treat your shoulder 
pain. The Plan denied your request. The Plan says the the requested services are 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 the injections. Our reviewer says that 
the requested peripheral nerve blocks are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical literature does not indicate that peripheral nerve blocks have been shown 
to treat chronic pain. Therefore, the reviewer found that the peripheral nerve blocks are not medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a peripheral nerve block (64418 x 2) and imaging guidance (76942).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve a SCS. 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 no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless 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 a SCS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record sent by the provider indicates that the enrollee has failed conservative management of his low back pain with therapy, injections, massage, 
ice, heat, topical pain medications, nerve pain blockers, exercise, electrical stimulation, Tylenol, and has been 
cleared for the procedure by a mental health professional. He has not failed narcotic pain medications and is 
unable to take anti-inflammatory medications due to his blood thinner. All trials which proceed to permanent 
implant must have adequate documentation in the chart to support that decision. A successful trial should be 
associated with at least a 50% reduction of target pain, or 50% reduction of analgesic medications, and show 
some element of functional improvement. The review has determined that the enrollee does not meet the 
coverage criteria detailed in the NCD. 
 
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 SCS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a spinal cord stimulator (SCS).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab service provided to the enrollee on June 18, 2021. 
 
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says the performance of multiple molecular tests regardless of whether the 
requisition lists the tests as a panel or individually and completed on a single sample is considered to be 
a Panel of tests and should be billed under a single code to prevent stacking of codes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim was billed incorrectly with 
multiple codes for the same service. Medicare rules for coverage of this claim have not been met. Therefore, 
we decided that the Plan does not have to pay for lab service provided to the enrollee on June 18, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services provided to the enrollee on May 16, 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 that procedure code 28854 is not supported by the medical records submitted. 
 
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 22854 is "Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral 
anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral 
corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody 
arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)." 
 
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 supported by the medical records. Our reviewer found that the procedure notes state that an LDR 
PEEK cage interior which had been filled with demineralized bone matrix was then countersunk under direct 
and fluoroscopic visualizations into the anterior partial corpectomy defect site at C4-5 in order to accomplish 
an anterior spinal arthrodesis mass at this level. Curved titanium plates of appropriate length were then inserted 
through the lumen of the PEEK cage to engage the vertebral bodies above and below and to accomplish 
anterior spinal instrumentation. Therefore, the records do support that CPT 22854 was rendered in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services provided to the enrollee on May 16, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, 
E2311, E2313, E2377) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the patient does not require a ventilator, or non-proportional input devices (e.g., sip and 
puff, head array, etc.). The patient does 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. The patient has  power options  on the wheelchair but the patient does not 
need to control the power options through a joystick. The patient's upper extremity strength and function 
supports that the patient 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 the accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the requested drug is not medically necessary. The Plan 
denied your request. The Plan says you have a bad sweating problem of the scalp. You say that you have 
cranial facial hyperdrosis. You also say that the requested injections are not for cosmetic reasons. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that the 
requested Botox is not medically necessary. Our physician reviewer found the Food and Drug Administration 
(FDA) has not stated that the requested Botox injection is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of Botox in the enrollee's clinical 
situation. Therefore, the reviewer found that the requested Botox is 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox injections (J0585).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral/facial photographic images (code D0350) provided on 
June 15, 2022. 
 
You asked the Plan to pay for oral/facial photographic images. The Plan denied your request. The Plan says 
oral/facial photographic images are not covered under any circumstances. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral/facial 
photographic images (code D0350) provided on June 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77012 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 77012. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 77012 is bundled into payment for code 36573. 
 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 77012 
is a column II code to column I code 36573. 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 77012 billed for date of service June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's 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, for 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 March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric patient lift. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that patient lifts 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
Parkinson's disease. The records do not support that a standard lift device would not meet the enrollee's needs. The electric lift is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electric patient lift.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded with procedure codes 81225, 
81227, 81230, 81231, 81232, 81306, 0031U, 0032U and 0033U provided March 30, 2022. 
 You asked the Plan to pay for the genetic testing. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's medical condition. The Plan denied your 
request. The Plan says does not meet Medicare NCD/LCD criteria. The records do not support that the 
referring/ordering provider indicated is/was treating the enrollee. 
 
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. Outreach to the referring/ordering provider listed on the claim was 
made by the Plan and the doctor's office indicated that this is not one of their providers. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the genetic testing coded with procedure codes 81225, 81227, 
81230, 81231, 81232, 81306, 0031U, 0032U and 0033U provided March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan has to pre-approve a TFESI at two levels. We decided that the Plan does not have to 
pre-approve a TFESI at the third level. 
 
You asked the Plan to pre-approve repeat transforaminal epidural steroid injection (TFESI) at three levels.. You 
say that you disagree with the denial. The Plan says that the services are not medically necessary. 
 
We decided that the Plan has to pre-approve a TFESI at two levels.  
 
The Plan must follow Medicare rules. Medicare rules say that a TFESI is 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 these services. Our reviewer says that 
the TFESI at two levels is medically necessary. Our physician reviewer found the enrollee has chronic low 
back pain and lumbar radiculopathy. She had three levels of an ESI with goof effect. The request for a repeat 
TFESI at the third level exceeds the utilization limit in the Medicare rules. The repeat TFESI at two levels is 
medically necessary. The third level is 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 these services have not been met.  Therefore, we decided that the Plan has to 
pre-approve a TFESI at two levels.  
 
We also decided that the Plan does not have to pre-approve a TFESI at the third level. 
 
We looked at this physician's review, the file, and Medicare rules. The physician reviewer states that the TFESI 
at the third level is not medically necessary. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a TFESI at the third level. 
 
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.