Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
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 this is medically necessary. 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 Intracept procedure. 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. More research is needed before coverage can 
be approved. 
 
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: 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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee can receive the care needed at an 
alternate level of care. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis.  
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint/ 
 
You asked the Plan to pre-approve RFA services. You say that this care is medically reasonable and necessary. 
The Plan denied your request. The Plan says the requested RFA services are not medically reasonable and 
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 RFA services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a 59-year-old woman diagnosed with bilateral sacroiliitis.  Also, of concern is 
the fact that she has metastatic pancreatic carcinoma with metastatic to the lung, lymph nodes and spine. In this 
case, this is not cancer-related pain. The request for RFA is considered not medically reasonable or necessary 
as the peer reviewed literature relates that there is a very wide rate of efficacy for the services 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 RFA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint/
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 this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested Intracept procedure is not 
medically reasonable and necessary as it 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 Intracept procedure. 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. More research is needed before coverage can 
be approved. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open sacroiliac (SI) joint fusion. 
 
You asked the Plan to pre-approve open SI joint fusion. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of an open SI 
joint fusion procedure in absence of SI joint instability, fracture, or tumor have 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 open SI joint fusion. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation of SI joint instability, fracture or lesion. Open SI joint 
fusion for degenerative back pain 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 open SI joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve open sacroiliac (SI) joint fusion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision supply, accessory and/or service component provided 
on April 19, 2022. 
 
You asked the Plan to pay for vision supply, accessory and/or service component. You say that you never 
received a supply and/or accessory and you believe the provider made a billing error. The Plan denied your 
request. The Plan says the provider has confirmed that the $25.00 fee is for a 1-year protection for eyewear not 
a copay. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that a 1-year protection for eyewear is not a covered 
vision benefit. Therefore, we decided that the Plan does not have to pay for vision supply, accessory and/or 
service component provided on April 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that home health services are medically 
necessary for your condition. The Plan denied your request. The Plan says the criteria for home health services 
have not been met. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically reasonable and necessary. Our physician 
reviewer found you are an 83-year-old female with macular generation who is legally blind. Based on the 
limited documentation provided, you do not have documented skilled nursing needs. Furthermore, you do not 
have documented skilled therapy needs. As such, home health services, including associated home health aide 
services, are not shown to be medically necessary or reasonable for your medical conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81162) provided October 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this test was for screening purposes and is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1/BRCA2 genetic testing is not covered 
for testing of individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, 
pancreatic, or prostate cancer. 
 
We looked at the file and Medicare rules. The record shows no personal cancer history. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (81162) provided October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 25, 2022, billed 
with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81306, 81335, and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says this panel was not correctly billed with a single panel code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 25, 2022, billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81306, 81335, and 
81355.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting 
reconsideration for the denial of additional transportation trips. The Plan denied your request. The Plan says 
you have exhausted the maximum benefit of 24 one-way trips per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient detox treatment. 
 
You asked the Plan to pre-approve inpatient detox treatment. You say that there is no facility that want to work 
with the plan. You also say you need detox and rehab. The plan only has teletherapy and mental institutions. 
The Plan denied your request. The Plan says the requested facility does not participate in 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 facility at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve inpatient detox treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on February 19, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for an office visit (99213) provided on February 19, 2022 by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear provided on December 28, 2021. 
 
You asked the Plan to pay for eyewear. The Plan denied your request. The Plan says your current Plan does not 
have a routine eyewear benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for eyewear provided on December 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided along 
with drug testing on November 11, 2021, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry testing. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says the drug testing was approved for payment. However, 
no payment can be made for the validity testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the unspecified mass spectrometry testing have not been met. Specifically, we find that the testing 
described by the billed code is considered specimen validity testing which is not separately payable. Therefore, 
we decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided along 
with drug testing on November 11, 2021, billed with code 83789.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power wheelchair (K0899) provided on April 1, 2021. 
 
You asked the Plan to pay for the power wheelchair. You say that the wheelchair was medically necessary. The 
Plan denied your request. The Plan says no pre-authorization was requested for the power wheelchair. 
 
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 Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for 
these services. Therefore, we decided that the Plan does not have to pay for a power wheelchair (K0899) 
provided on April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous transcatheter placement of intracoronary 
stent(s), with coronary angioplasty when performed; single major coronary artery or branch (92928). 
 
You asked the Plan to pre-approve a percutaneous transcatheter placement. You say that the requested 
procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure does 
not meet the requirements for approval. 
 
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 a percutaneous transcatheter placement. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you have no history of chest pain. A previous radionuclide stress test 
was negative on 6/29/2022. LV function is normal by echocardiogram. Guidelines do not support a need for 
PCI in this setting. As a result, at this time PCI would not be considered medically appropriate and necessary in 
your clinical 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 a percutaneous transcatheter placement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a percutaneous transcatheter placement of intracoronary 
stent(s), with coronary angioplasty when performed; single major coronary artery or branch (92928).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be 
medically necessary for your condition. The Plan denied your request. The Plan says the continuation of SNF 
care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continuation of SNF care. Our 
reviewer says that the requested SNF care is no longer medically reasonable and necessary. Our physician 
reviewer found based on the documentation provided, you do not have documented skilled nursing needs. In 
addition, you do not have documented skilled therapy needs. You are currently ambulating more than 100 feet 
and tending to activities of daily living with minimal supervision. Daily skilled services are not shown to be 
required to establish a maintenance program or to prevent deterioration of your condition. Your care needs can, 
as a practical matter, be provided 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 the continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye surgery (66984, V2632) provided April 
12, 2022. 
 
You asked the Plan to waive the copayment for the eye surgery. You say that the copayment should be waived. 
The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 a $150 
copayment for outpatient surgery.  
 
You have been asked to pay a $150 copayment for the eye surgery. The eye surgery falls within the outpatient 
surgery benefit category. 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 copayment for eye surgery (66984, 
V2632) provided April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) genetic testing panel 
provided on December 20, 2021. 
 
You asked the Plan to pay for the F1CDx panel. You say that this is a Food and Drug Administration approved 
test that is covered by a Medicare National Coverage Determination. The Plan denied your request. The Plan 
says billing rules require that molecular diagnostic tests be reported with the appropriate Z-code on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that testing such as F1CDx must be approved through 
the MolDX contractor and assigned a Z-code. This Z-code must be reported along with the CPT code for 
payment.  
 
We looked at the file and Medicare rules. The claim submitted does not include a Z-code. Based on this 
information, we decided that Medicare rules for coverage of the F1CDx panel have not been met. Therefore, 
we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) genetic testing panel 
provided on December 20, 2021.