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

 
We decided that the Plan does not have to pre-approve acupuncture with a non-contract provider. 
 
You asked the Plan to pre-approve the acupuncture. You say that you have surgery coming up and would like 
to have acupuncture while you wait. The Plan denied your request. The Plan says the requested provider is not 
a contract provider and acupuncture was approved with a contracted provider. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the requested provider is not a contracted 
acupuncturist. The Plan has approved the services with a contract provider. Therefore, we decided the Plan 
does not have to pre-approve acupuncture with a non-contract provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency (RFA) of the sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve SI joint RFA. You say that you discussed every other option with your 
doctor and this was the mutual agreement. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this procedure has not been proven as effective as standard 
treatments for sacroiliac (SI) pain. 
 
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 SI joint RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is considered experimental and investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency (RFA) of the sacroiliac (SI) joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Inogen system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the current oxygen system is comparable in weight to the Inogen product being 
requested. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 system Our reviewer says that the 
requested system is not medically reasonable or necessary. Our physician reviewer found that the record 
indicates that you have approved for and has a portable oxygen system. The record provided does not establish 
the medical necessity of the specific service requested. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Inogen system.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 36246. We decided that the Plan does not have to pay for 75710.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the denied 
codes are not supported in the records submitted. 
 
We decided that the Plan has to pay for 36246.  
 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 
CPT 36246 is "Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower 
extremity artery branch, within a vascular family." 
 
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 for CPT 36246. Our reviewer says that this code is 
documented in the report as a catheter was selectively placed into the popliteal artery. Such a placement 
conforms with the requirements for this code. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
36246.  
 
We also decided that the Plan does not have to pay for 75710. 
 
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 
CPT 75710 is "Angiography, extremity, unilateral, radiological supervision and interpretation." 
 
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 for CPT 75710. Our reviewer says that CPT 75710-26-
59RT is selective angiography and is considered to be a part of the already billed procedure, CPT 34201-RT, 
the thrombolectomy and thus should not be separately reimbursed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 75710 have not been met. Therefore, we decided that the Plan does not have to 
pay for 75710. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 10009 billed for date of service September 
27, 2021. 
 You asked the Plan to pay for procedure code 10009. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says payment for code 10009 is bundled 
into payment for code 20206. 
 
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 10009 
is a column II code to column I code 20206. 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 10009 billed for date of service September 27, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Zenith amniotic membrane. 
 
You asked the Plan to pre-approve the Zenith Amniotic membrane. You say that the patient's foot will heal 
much faster with this membrane.  The patient has had previous amputation of the left foot and you are trying to 
provide amputation of the other foot. The Plan denied your request. The Plan says the use of the Zenith 
amniotic membrane is considered experimental/investigational for all indications. 
 
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 Zenith Amniotic membrane. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found it is well documented that this patient has undergone surgery to their right 
foot. They have subsequently developed an ulceration that as of June 8, 2022, measured 5.5 cm by 1.1 cm. The 
wound was noted to measure 7.0 cm x 2.0 cm on May 9, 2022. There has been considerable reduction in the 
ulceration size in roughly one month with care including debridement, wound dressings, offloading, and Santyl 
ointment.  It has been requested that the patient received a Zenith amniotic membrane covering to their 
ulceration. Medicare advises that they will pay for items or services that are reasonable and necessary for the 
diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. However, these treatments must be safe and effective, not mainly for the convenience of the patient or the 
physician, not experimental or investigational, and appropriate  furnished in accordance with accepted 
standards of medical practice for the diagnosis or treatment of the patients condition. In this particular case, in 
only one month, the ulceration has had a considerable reduction in size. It does not appear that the Zenith 
amniotic membrane covering is technically medically necessary as long as the patient continues to improve 
with standard of care wound care and dressings. Therefore, it is my opinion that the requested Zenith amniotic 
membrane is not medically reasonable or necessary at this time. 
 
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 Zenith Amniotic membrane have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Zenith amniotic membrane.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this procedure is safe and effective and is medically 
necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the clinical value and effectiveness of this procedure has not been demonstrated in the peer-reviewed 
literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on January 24, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is a Medicare-covered test and should be 
covered. The Plan denied your request. The Plan says that any panel that tests for the Fanconi anemia 
complementation group C (FANCC) gene is noncovered. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on January 24, 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: 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 enrollee meets IRF admission criteria. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that the enrollee will be able to fully participate in 
- and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance (MRI). 
 
You asked the Plan to pre-approve the MRI. You say that you are requesting an appeal for the denial of the 
MRI stating that it is medically necessary. The Plan denied your request. The Plan says that the service 
requested does not meet Medicare criteria. 
 
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 the MRI. Our reviewer says that the 
requested MRI lumbar spine should be approved. Our physician reviewer found the enrollee has low back pain 
and left radicular symptoms. There is no weakness or absent reflex however the enrollee has been treated with 
a 5-day course of steroids with no relief. The enrollee also has a history of rheumatoid arthritis. Due to the 
enrollee's underlying rheumatoid arthritis and the course of steroids without relief the criteria of medically 
necessity of the MRI have been met absent a 6 week trial of physical therapy. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance (MRI).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient surgery provided on October 22, 
2021, to March 4, 2022. 
 
You asked the Plan to waive the cost share for outpatient surgery. You say that the provider billed incorrectly 
for services received in the doctor's office. The Plan denied your request. The Plan says coinsurance is applied 
correctly 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each Medicare-covered item, $275 copayment for each Medicare-covered outpatient surgery at 
a hospital outpatient facility, $35 copayment for physician specialist services (including surgery second 
opinion, telehealth, and urgently needed services).  
 
  You have been asked to pay $945.81 for outpatient surgery. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
October 22, 2021 Outpatient surgery $489.55 $275 $275 
November 5, 2021 Outpatient surgery $322.99 $275 $275 
December 3, 2021 Medical supplies $79.05 20% $15.81 
December 10, 2021 Office visit $66.48 $35 $35 
December 17, 2021 Office visit $66.48 $35 $35 
January 7, 2021 Outpatient surgery $331.29 $275 $275 
March 4, 2021 Office visit $65.93 $35 $35 
TOTAL:    $945.81 
 
Outpatient surgery falls within the Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers. Medical supplies fall within the Durable medical equipment (DME) 
and related supplies. Office visits fall within the Physician/Practitioner services, including doctors office visits 
benefit categories. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost share for outpatient surgery provided on 
October 22, 2021, to March 4, 2022.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve two additional visits. We decided that the Plan does not have to 
pre-approve four additional visits.   
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan says 
that Medicare states that for ongoing therapy to be covered, ongoing medical necessity must be demonstrated in 
the form of progress notes that should be provided at least once every ten treatment days. 
 
We decided that the Plan has to pre-approve two additional visits.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 for the visits. Our reviewer says that two additional 
visits should be completed as part of discharge Our physician reviewer found completing home exercise 
program training and preparing the enrollee to practice at home is medically reasonable and necessary. Two 
visits should be authorized to complete discharge as the enrollee needs to have an adequate discharge process. 
 
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 additional visits have been met. Therefore, we decided that the Plan has to 
pre-approve two additional visits.  
 
We also decided that the Plan does not have to pre-approve four additional visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 for the additional visits. Our reviewer says that the 
enrollee has increased his endurance with standing in parallel bars but endurance training is not a skilled 
service. He has not been able to alter his transfer capability. He is now independent in the home exercise 
program. The goals of care are for improvement but without neurological improvement therapy has little 
impact. The enrollee requires repetitive exercise to improve his transfer technique and endurance. The unique 
skills and insight of the therapist have been provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of four additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four additional visits. 
 
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.