Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve (64628). 
 
You asked the Plan to pre-approve the thermal destruction of intraosseous basivertebral nerve. You say that the 
intracept procedure is medically necessary and supported by strong science. The Plan denied your request. The 
Plan says this treatment cannot be approved because this type of treatment 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 thermal destruction of intraosseous 
basivertebral nerve. Our reviewer says that the thermal destruction of intraosseous basivertebral nerve is not 
considered medically reasonable and necessary in this case. Our physician reviewer found the 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. Our reviewer found that 
the documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as 
being medically necessary and/or reasonable at this time. Our physician reviewer also found that 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 thermal destruction of intraosseous basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the thermal destruction of intraosseous 
basivertebral nerve (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on October 27, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on June 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) (43235). 
 
You asked the Plan to pre-approve an EGD. The Plan denied your request. The Plan says this request cannot be 
approved because a detailed history and physical exam results were not received showing this study is needed. 
 
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 an EGD. Our reviewer says that an 
EGD is not considered medically reasonable and necessary in this case. Our physician reviewer found the 
enrollee has longstanding gastroesophageal reflux disease (GERD), but their 2013 EGD as provided did not 
demonstrate Barrett's nor histologic changes that warrant a repeat EGD exam. The enrollee is not currently 
reporting recurrent dysphagia, nor has their diminished appetite resulted in unexplained weight loss. Our 
reviewer found that the enrollee's trial of low-dose Omeprazole for 14 days is considered inadequate to assess 
their proton pump inhibitors (PPI) response. Specialty society guidance considers instead an appropriate PPI 
trial for GERD to be no less than daily use for 8 weeks, in concert with curtailment of the enrollee's 
refluxogenic lifestyle. Our physician reviewer also found that an EGD can be reconsidered thereafter, 
supported by provided medical documentation, if symptom response proves incomplete, or sooner if red flag 
signs and symptoms develop. 
 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 EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an esophagogastroduodenoscopy (EGD) (43235).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
requested use is not supported as medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that electrocardiographic services are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that while the enrollee has a history of atrial fibrillation and stroke, there is no documentation 
provided to suggest a history of unexplained syncope or any other apparent indication for an ILR. In summary, 
there is insufficient documentation to support the medical necessity in this enrollees 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an implantable loop recorder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 1, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the provider 
did not rebill the claim until over 12 months after the initial was processed with no rationale for late filing. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for physician's services was not filed until September 16, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 11, 2022, billed with 
codes 81206, 81210, 87235, 81275, 87276, 87292, 81295, 81298, 81301, 81317, 81401, 81194 and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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 
January 11, 2022, billed with codes 81206, 81210, 87235, 81275, 87276, 87292, 81295, 81298, 81301, 81317, 
81401, 81194 and 81309.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service July 13, 
2022. 
 
You asked the Plan to pay for procedure code 99072. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99072 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 5, 2022, billed with 
codes 81206, 81210, 81235, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194, and 81309. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
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 
March 5, 2022, billed with codes 81206, 81210, 81235, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 
81194, and 81309.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ultomiris. 
 
You asked the Plan to pre-approve Ultomiris. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not been 
met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ultomiris. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of mycophenolate mofetil with oral glucocorticoids before they will approve the requested 
drug, Ultomiris. There is no indication in the medical records provided that the enrollee has tried and failed the 
required drugs. Based on the medical records provided and the Medicare-approved major drug compendia, 
there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse 
effects for the 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 Ultomiris have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Ultomiris.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided to the enrollee on July 19, 2022. 
 
You asked the Plan to pay for the service. You say that this hould be paid for. The Plan denied your request. 
The Plan says the records indicate that the servicing provider rendered surgery procedure code 52000 on the 
date of service July 19, 2022, and also performed procedure code 99213 on the same date. 
 
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 99213 is not supported in the medical record. Specifically, the global surgery period for 
CPT 52000 is 0 days as a minor or endoscopic procedure that has a global surgery period of 0 days. Therefore, 
CPT 99213 should not have been reported separately on the same day. Based on this information, we decided 
that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for an office visit provided to the enrollee on July 19, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the head or brain (70450). 
 
You asked the Plan to pre-approve a CT of the head or brain. The Plan denied your request. The Plan says that 
the documentation states you had repeat imaging on November 21, 2022, with near complete resolution of 
previous bleed and there was no hydrocephalus noted. The Plan also says the requested imaging remains 
upheld at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT of the head or brain. Our reviewer 
says that a CT of the head or brain is reasonable and necessary for you. Our physician reviewer found you had 
evacuation of an acute subdural hematoma and are chronically medicated with Plavix and Aspirin for vascular 
disease. You had both subdural and subarachnoid bleeding, and your medications have been restarted. Our 
reviewer also found that it is medically necessary to ensure your hemorrhages have resolved in order to 
continue to use these medications which are fundamentally anti-thrombolytics, and their use places any patient 
at risk for intracranial hemorrhage let alone a patient with a recent history of acute bleed. 
 
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 CT of the head or brain have been met. Therefore, we decided that the Plan 
has to pre-approve a computed tomography (CT) of the head or brain (70450).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. The Plan denied your request. The Plan says the 
coverage criteria are not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM and supplies. Our reviewer says 
that the requested CGM and supplies are not medically reasonable and necessary. Our physician reviewer 
found that the enrollee is not on multiple daily injections of insulin.  
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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on March 11, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not processed by the primary insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the Plan 
requested an Explanation of Benefits (EOB) from the primary insurer on seven different occasions from 
October 19, 2022, to November 9, 2022. As the secondary insurer, the Plan cannot be held responsible for these 
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for the emergency room (ER) services rendered on March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on August 24, 2022. 
 
You asked the Plan to pay for injections. You say that you are requesting reconsideration. 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 injections provided on 
August 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93976 billed for date of service December 
10, 2021. 
 
You asked the Plan to pay for procedure code 93976. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93976 is bundled into payment for code 76856.  
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 93976 
is a column II code to column I code 76856. 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 93976 billed for date of service December 10, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for procedure code 85060. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this service was not billed in accordance with 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85060 have not been met. Specifically, the record shows that this service was furnished to an enrollee in an outpatient hospital (Place of Service code 22) setting. Therefore, we decided that 
the Plan does not have to pay for procedure code 85060 billed for date of service July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair (E1399) purchased July 27, 2022 
 
You asked the Plan to pay for the power wheelchair. You say that the insurance Plan states that it covers 
wheelchairs, yet this was denied. The enrollee needs this wheelchair 90% of the time because of severe 
arthritis. The Plan denied your request. The Plan says the power wheelchair, incorrectly coded as E1399, does 
not meet the requirements for approval. The Medicare criteria for power wheelchair has not been 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 power wheelchair have been met. 
The limited medical records submitted include a physical therapy wheelchair evaluation on July 27, 2022 (3 
months after purchasing the power wheelchair). Despite multiple requests for further records from your doctor, 
none were received. There was no physician signed seven element order, face to face examination with your 
provider, physician signed detailed product description order, or home assessment provided. Therefore, we 
decided that the Plan does not have to pay for the power wheelchair (E1399) purchased July 27, 2022