Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says the provider is out-of-network, and it was determined these services 
can be received 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 an office visit provided on August 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous nerve ablation (64628). 
 
You asked the Plan to pre-approve the nerve ablation. You say that the service is necessary for the enrollee. 
The Plan denied your request. The Plan says the requested service 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 the nerve ablation. Our reviewer says 
that the requested nerve ablation is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested nerve ablation is considered experimental. Therefore, the reviewer 
found that the requested service 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 the nerve ablation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intraosseous nerve ablation (64628).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the spinal canal 
and contents. 
 
You asked the Plan to pre-approve an MRI of the spinal canal and contents. You say that this MRI is medically 
necessary to determine why the enrollee is having abnormal sensation and new episodes of pain. The Plan 
denied your request. The Plan says the enrollee has not completed six weeks of therapy within the last three 
months. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the spinal canal and 
contents. Our reviewer says that an MRI of the spinal canal and contents is not reasonable and necessary for the 
enrollee. Our physician reviewer found the notes state the enrollee has done some physical therapy, which has 
helped a little, but symptoms are still present. The submitted records offer no details of the physical therapy 
including dates, duration, assessment, etc. Our physician reviewer also found that the medical necessity of the 
requested MRI of the cervical spine cannot be determined without any red flag to mandate immediate MRI. 
 
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 MRI of the spinal canal and contents have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the spinal canal and 
contents.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Alimta provided on July 4, 2022. 
 
You asked the Plan to pay for Alimta. You say that this was medically necessary. The Plan denied your 
request. The Plan says that this use is experimental. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 pay for Alimta. Our reviewer says that the requested 
use of Alimta is supported. Our physician reviewer found Alimta is Food and Drug Administration (FDA) 
approved for single-agent treatment of recurrent/metastatic nonsquamous non-small cell lung cancer (NSCLC) 
after prior chemotherapy. Large cell neuroendocrine is a nonsquamous NSCLC. Alimta was safe, effective, and 
otherwise reasonable and necessary for this enrollee. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Alimta have been met. Therefore, we decided that the Plan has to pay for 
Alimta provided on July 4, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87502, 87503, and 87634 billed for date of 
service September 10, 2021. 
 
You asked the Plan to pay for procedure codes 87502, 87503, and 87634. The Plan denied your request. The 
Plan says payment for codes 87502, 87503, and 87634 is bundled into payment for code 87631.  
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 
87502, 87503, and 87634 are column II codes to column I code 87631. 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 87502, 87503, and 87634 
billed for date of service September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crutches underarm, other than wood, adjustable or fixed, 
pair, with pads, tips and handgrips (E0114) provided June 30, 2021. 
 
You asked the Plan to pay for the crutches. You say that you were unaware that you needed an authorization. 
You were strong armed into accepting the crutches. The Plan denied your request. The Plan says the request for 
coverage of crutches is not medically necessary because there is no clinical documentation of the medical 
necessity and no evidence that this item was ordered by a treating practitioner. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, signed physician order or medical records was 
submitted. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the crutches underarm, other than 
wood, adjustable or fixed, pair, with pads, tips and handgrips (E0114) provided June 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical laparoscopy (51990) provided on September 14, 
2022. 
 
You asked the Plan to pay for the surgical laparoscopy (51990). You say that the required documents are 
attached and the claim should be reprocessed for payment. The Plan denied your request. The Plan says 
procedure code 51990 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 51990 is laparoscopy, surgical; urethral suspension for 
stress incontinence. 
 
  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 surgical laparoscopy (51990). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the operative report does not include sufficient documentation to confirm a bladder suspension procedure has 
been performed. 
 
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 surgical laparoscopy (51990) have not been met. Therefore, we decided that 
the Plan does not have to pay for the surgical laparoscopy (51990) provided on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus nP pharmacogenomic panel provided on May 16, 
2022. You asked the Plan to pay for the pharmacogenomic panel. You say that this test was medically necessary. 
 The Plan denied your request. The Plan says the criteria for coverage of this test are not met. 
 
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 the pharmacogenomic panel have been 
met. Specifically, the records provided do not include any medical records or progress notes from the referring 
physician or a signed physician order. Therefore, we decided that the Plan does not have to pay for Tempus nP 
pharmacogenomic panel provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure fills a treatment gap for 
enrollees that do not receive adequate relief from traditional conservative methods and do not have instability 
to indicate that fusion is the appropriate treatment. The Plan denied your request. The Plan says the requested 
procedure 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested Intracept procedure is considered experimental for back pain. 
Therefore, the reviewer found that the requested procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on May 13, 2022. 
 
You asked the Plan to pay for the general health panel. You say that your lab services have never been denied 
before. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is not covered or 
paid for by Medicare. You have requested payment for services billed under code 80050. Medicare does not 
cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for 
the general health panel (80050) provided on May 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD.  
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 home ventilator. Our reviewer says 
that this item is not medically necessary. Our physician reviewer found there is no evidence of chronic 
respiratory failure due to chronic obstructive pulmonary disease (COPD). 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter tricuspid valve repair (TTVR) surgery. 
 
You asked the Plan to pre-approve TTVR surgery. You say that the clinical information provided supports the 
need for the requested surgery. The Plan denied your request. The Plan says transcatheter tricuspid valve repair 
with the Mitra Clip system is not medically necessary based on the available peer-reviewed literature and 
society guidelines. 
 
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 TTVR surgery. Our reviewer says that 
TTVR surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee has a history of severe tricuspid regurgitation. There are insufficient randomized clinical data at 
this time to support the use of TTVR in this setting. As such, it would not be considered medically appropriate 
and necessary in this enrollee's 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 TTVR surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter tricuspid valve repair (TTVR) surgery.
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. 
 
You asked the Plan to pre-approve IRF care. 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 must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee can receive further 
services 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 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20650 and 76000 provided on March 16, 
2022. 
 
You asked the Plan to pay for procedure codes 20650 and 76000. You say that these services were rendered in 
an emergency setting where the decision to perform surgery was crucial. You say that these codes are 
medically covered procedures under CMS guidelines and are payable. The Plan denied your request. The Plan 
says procedure codes 20650 and 76000 are considered inclusive to procedure code 27245.  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 20650 and 76000 are column II codes to column I code 27245; 
however, 20650 and 76000 were billed with a modifier.  
 
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 procedure codes 20650 and 76000. Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report describes an open treatment of right intertrochanteric femur fracture with traction pin under 
fluoroscopy. In this case, the insertion of traction pin would be considered the treatment for the femur fracture 
and the fluoroscopy services are included in the fracture treatment. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 20650 and 76000 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 20650 and 76000 provided on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 7, 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 this would need to have modifier 26 on the claim. 
 
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 CPT code 88341, 88342, and 88360 is not supported in the medical record. Specifically, these 
codes would require the use of modifier 26 as the professional interpretation of a diagnostic test must be 
separately billed. 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 April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Purewick Urine Collection System. 
 
You asked the Plan to pay for the incontinence supplies. The Plan denied your request. The Plan says this is not 
a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for the Purewick Urine Collection 
System.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc matrix injection services. 
 
You asked the Plan to pre-approve the VIA Disc matrix injection services. You say that this procedure is 
medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says 
the requested procedure is considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the VIA Disc matrix injection services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the enrollee is a 47-year-old female being treated for intervertebral 
disc degeneration of the lumbar region. She presented with lower back pain radiating down the bilateral lower 
extremities. The previous epidural injection on August 23, 2022, at left L5/S1 and S1/S2 provided 50% relief 
for the first two days. She has ongoing pain in the previous area and feels the left foot drop has worsened. The 
back pain has been present for years and is progressively worsening. The exam reveals bilateral pain with 
palpation of the facets at L4-S1 and over the bilateral buttocks. Straight leg raise was positive for radiating pain 
on the left. There is limited flexion and extension with pain. Provocative maneuvers for lumbar facet were positive bilaterally. There is trace foot drop on the left. Strength was decreased on the lower extremities at 4-/5 
on the left and 4+/5 on the right. 
 
In this case, there is limited published, large-scale, long-term peer-reviewed literature that shows this requested 
procedure to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested VIA Disc matrix injection, in this case, is not medically 
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 VIA Disc matrix injection services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the VIA Disc matrix injection services.