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

 
We decided that the Plan does not have to pay for the nursing facility care provided on February 16, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the enrollee developed pneumonia. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nursing facility care 
provided on February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, 88365 and 88381 
billed for date of service March 16, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88360, 88365 and 88381. You say that these 
services were necessary and are supported as billed. The Plan denied your request. The Plan says these services 
were not reported in accordance with Medicare billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that procedure codes 88341, 88342, 88360, 88365 and 88381 are physician pathology services which 
have both professional components (PC) and technical components. These services were not billed with 
modifier 26 to indicate that only the professional component payment is requested. This means that payment is 
requested for both the PC and TC of these services. However, these services were provided to an enrollee who 
was in an outpatient hospital setting at the time the sample was collected, which means that the TC component 
is bundled into the facility payment. The TC portion of these services are not separately payable, and therefore 
these services are not supported as billed. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 88341, 88342, 88360, 88365 and 88381 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 88341, 88342, 88360, 88365 and 88381 billed for date 
of service March 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 16, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 9, 
2022 to March 10, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive 
skilled therapy during the requested period from February 9, 2022, to March 10, 2022. 
 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from February 9, 2022 to March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the seat lift mechanism, electric, any type (E0627) 
and miscellaneous durable medical equipment (E1399) purchased August 29, 2021. 
 
You asked the Plan to reimburse you for the durable medical equipment. You say that you would like to appeal 
the denial of reimbursement. The Plan denied your request. The Plan says items was purchased from a supplier 
who is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the seat lift mechanism, 
electric, any type (E0627) and miscellaneous durable medical equipment (E1399) purchased August 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel testing provided on June 1, 
2022. 
 
You asked the Plan to pay for the testing services. You say that the specimens are received from providers who 
have performed biopsies. The Plan denied your request. The Plan says the testing is non-covered. 
 
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. Panels with more than 5 pathogens are not covered.  Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the respiratory pathogen panel testing provided on June 1, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the injection of alprostadil provided on July 18, 2022. 
 
You asked the Plan to pay for the injection of alprostadil. You say that you were not told this injection would 
not be covered. The Plan denied your request. The Plan says that Medicare does not provide coverage for 
injection procedures to induce an erection. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for an injection of alprostadil. Our reviewer says 
that the injection of alprostadil is medically necessary. Our physician reviewer found intracavernosal injections 
given a physician's office are covered by Medicare because these injections are for diagnostic and instructional 
purposes. The injection of corpora cavernosa with alprostadil does 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 an injection of alprostadil have been met. Therefore, we decided that the Plan 
has to pay for an injection of corpora cavernosa with pharmacologic agents (injection of alprostadil) provided 
on July 18, 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 needs an IRF admission. The Plan 
denied your request. The Plan says the services needed 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. Our 
physician reviewer found there is no indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain her functional status. The member 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, G0480) provided on May 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 (80307, G0480) provided on May 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is presently receiving appropriate services in the acute care setting. 
Continued care in the acute hospital is appropriate until the enrollee is stable to transfer to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy services. 
 
You asked the Plan to pre-approve knee arthroscopy 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 not medically necessary as the provided clinical documentation does not indicate that 
the enrollee has attempted trials of nonoperative therapy with physical medicine treatments, oral medications 
joint injections or other possible treatment 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 knee arthroscopy 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 65-year-old male being treated for a complex tear of 
the medial meniscus. He presented with left knee pain. The pain has been present for the past 2-3 weeks. The 
pain will be focused mostly over the medial aspect of the knee. Height is 73 inches, weight is 207.2 pounds, 
and body mass index is 27.3 kg/m2. The left knee exam reveals trace effusion. There is mild medial joint line 
tenderness to palpation, minimal lateral joint line tenderness to palpation.  
In this case, detailed documentation is not evident regarding a trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. There are no mechanical symptoms corroborated on 
the objective exam. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
knee arthroscopy services, 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 knee arthroscopy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve knee arthroscopy services.
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 the Intracept procedure. You say that the clinical documentation provided 
supports the need for the requested procedure. The Plan denied your request. The Plan says there is not enough 
medical evidence that shows this procedure is as safe and as effective as other standard treatment options. The 
Plan says that this procedure is 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain.  Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time.  There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 17, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA disc allograft injection services. 
 
You asked the Plan to pre-approve VIA disc allograft 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 VIA disc allograft 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 this 72-year-old male was being treated for lumbago with sciatica. 
He presented with lower back pain radiating to the bilateral groin area and right lower extremity. The right 
L4/5 and L5/S1 transforaminal epidural steroid injection provided on August 23, 2022, provided greater than 
50% relief. In this case, there is limited published, large-scale, long-term peer-reviewed literature that shows 
the requested VIA disc allograft injection 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 allograft at L4/5, 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 VIA disc allograft injection services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve VIA disc allograft injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on July 27, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the psychotherapy services were medically 
necessary. The Plan denied your request. The Plan says there is no documentation that a psychiatric disorder 
currently exists, and there is lack of documentation of active symptoms either through observation or testing. 
 
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 pay for psychotherapy. Our reviewer says that the 
requested psychotherapy was not considered medically reasonable and necessary in this case. Our physician 
reviewer found that based on review the records provided, the enrollee was not showing any symptoms of her 
illness including depression, withdrawal, isolation, poor hygiene or psychomotor retardation. The enrollee did 
not have any suicidal or homicidal thoughts. Based on review the records provided this enrollee is not showing any symptoms of her illness, which would require the enrollee to be seen for individual psychotherapy. The 
psychotherapy performed was not found to be 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 psychotherapy have not been met. Therefore, we decided that the Plan does not 
have to pay for psychotherapy provided on July 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on July 14, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the provided item. You say that you thought you could purchase from any 
provider since your doctor was in-network. The Plan denied your request. The Plan says the provider is not a 
contracted supplier. 
 
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 item at issue in this appeal. The Plan did not pre-approve the item at 
issue. We found no exception that would require the Plan to pay for the provided item. Therefore, we decided 
that the Plan does not have to pay for the durable medical equipment provided on July 14, 2022, by an out-of-
network (OON) provider.