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

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet joint with image guidance, cervical or thoracic; single level (64490) and injection(s), 
diagnostic or therapeutic agent, paravertebral facet joint with image guidance, cervical or thoracic; second level 
(64491). 
 
 
 
 You asked the Plan to pre-approve injections. You say that you are requesting reconsideration of the injections 
due to cervical disc degeneration. The Plan denied your request. The Plan says the request is not medically 
necessary because records show the enrollee does not have documented failure to noninvasive conservative 
measures as she has no indication of trying physical therapy or other conservative measures. The enrollee has 
no radiology studies to show that there is no non-facet pathology causing her 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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of chronic neck and low back pain due to cervical disc disease, 
cervical spondylosis, lumbar disc disease, lumbar spondylosis and sacroiliitis. She has been treated with 
medical therapy. There is no documented failure to respond to non-invasive conservative management and no 
non-facet pathology per clinical assessment or radiology studies that could explain the source of the enrollee's 
pain, including but not limited to fracture, tumor, infection, or significant deformity. The review has 
determined that the enrollee does not meet criteria for the requested injections. The requested injections are not 
medically necessary 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet joint with image guidance, 
cervical or thoracic; single level (64490) and injection(s), diagnostic or therapeutic agent, paravertebral facet 
joint with image guidance, cervical or thoracic; second level (64491).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (21402, 24359) provided on June 7, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says these codes are 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 CPT code. 
 
We find that CPT codes 21402 & 24359 are not supported in the medical record. Specifically, these codes are 
included in the primary surgical procedure (24343). Based on this information, we decided that Medicare rules 
for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to 
pay for surgical services (21402, 24359) provided on June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69209 billed for date of service August 29, 
2022. 
 You asked the Plan to pay for procedure code 69209. You say that the documentation supports the medical 
necessity of services. 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 69209 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 69209 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 69209 billed for date of service August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 microprocessor knee and special cover.  

You asked the Plan to pre-approve a K3 microprocessor knee and special cover. You say that you are 
requesting reconsideration for the enrollee's left transfemoral components. The Plan denied your request. The 
Plan says the request for K3 microprocessor knee and special cover exceeds the enrollee's need and does not 
meet Medicare criteria as 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 a K3 microprocessor knee and special 
cover. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the microprocessor knee is a more advanced system. The 
enrollee does basic community ambulation at best. The need for a microprocessor knee versus other prosthetic 
knees is not addressed. The microprocessor knee has unclear advantage over other knee systems for most 
patients with an above knee amputation. There is no documentation of unusually harsh environmental 
situations for which a specialized lower limb prosthetic cover (L5964) is required, and for which approved 
prosthetic cover (L5705) would be insufficient. The criteria for a microprocessor knee and special cover are not 
met. 
 
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 K3 microprocessor knee and special cover have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a K3 microprocessor knee and special cover.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 21, 2022, billed with 
multiple codes including 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. 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 
August 21, 2022, billed with multiple codes including 81272.
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 you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the member does not 
meet the Medicare criteria for LTACH services. 
 
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 medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning 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 the spinal cord stimulator trial (63650). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical information provided does not present a coverable 
condition/situation provided in the LCD. 
 
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 service. Our physician reviewer 
found detailed documentation is not evident regarding lumbosacral arachnoiditis that has not responded to 
medical management. There is no indication of nerve root injuries. Complex regional pain syndrome I or II is 
not evident. There is no documentation of any amputations or phantom limb syndrome. End-stage peripheral 
vascular disease is not corroborated or documented. Additionally, post-herpetic neuralgia, plexopathy, 
intercostal neuralgia, cauda equina injury, or spinal cord injury is not evident on the documentation provided. 
No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of 
this request as an exception. Therefore, the medical records provided do not meet the requirements listed in the 
LCD for Medicare coverage. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the spinal cord stimulator trial (63650).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the swingaway joystick hardware (E1028). We also decided that 
the Plan does not have to pre-approve the power seat elevation (E2300) and tie down kit (K0108).  
 
You asked the Plan to pre-approve the joystick hardware, power seat elevation, and tie down kit. You say that 
the requested items are medically necessary. The Plan denied your request. The Plan says that the joystick 
controller is not medically necessary. The Plan also says that the power seat elevation and tie down kit do not 
serve a medical purpose. 
 
We decided that the Plan has to pre-approve the swingaway joystick hardware (E1028). 
 
The Plan follows Medicare rules. Medicare rules say that swingaway hardware is used with remote joysticks or 
touchpads and coverage is based on medically necessity. 
 
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 joystick hardware. Our reviewer 
says that the coverage criteria has been met. Our physician reviewer found that the enrollee is non-ambulatory 
and requires a power wheelchair for mobility and performing her basic daily activities. The enrollee cannot 
ambulate with a walker or cane and is unable to propel a manual wheelchair due to weakness from her stroke. 
The swingaway hardware for the joystick to operate the power wheelchair is necessary to re-position the 
joystick so that the enrollee can transfer in and out of the power wheelchair. 
 
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 joystick hardware have been met. Therefore, we decided that the Plan has to 
pre-approve the swingaway joystick hardware (E1028).  
 
We also decided that the Plan does not have to pre-approve the power seat elevation (E2300) and tie 
down kit (K0108). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The power seat elevation and tie down kit do not serve a purpose that is primarily medical in nature. Therefore, 
we decided that the Plan does not have to pre-approve the power seat elevation (E2300) and tie down kit 
(K0108). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 10, 2022, billed with 
codes 81272 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. 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 
July 10, 2022, billed with codes 81272 and 81351.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99238 billed for date of service July 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided for review. The 
Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 99238 is not supported in the medical record. Specifically, the records do not show that 
the billed code was provided on the date of service at issue. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99238 billed for date of service July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve general anesthesia for radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says anesthesia is not covered. 
 
The Plan must follow Medicare rules. The rules say that general anesthesia is considered not medically 
reasonable and necessary for facet joint interventions. 
 
We looked at the file and Medicare rules. The requested service is anesthesia during facet joint interventions. 
This service is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not 
have to pre-approve general anesthesia for radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 87186 billed for date of service January 21, 
2022. 
 
You asked the Plan to pay for procedure code 87186. You say that you disagree with the plan's denial. The Plan 
denied your request. The Plan says payment for code 87186 is bundled into payment for code 87184. 
 
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 87186 
is a column II code to column I code 87184. 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 87186 billed for date of service January 21, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot (J9217). 
 You asked the Plan to pre-approve Lupron Depot. You say that the preferred drug is not accessible at this 
facility. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
Eligard. 
 
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 Lupron Depot. Our reviewer says that 
the step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drug. The reviewer found that the documentation 
does not support that Eligard would likely be less effective and/or would likely have adverse effects for the 
enrollee in this case. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot (J9217).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 22, 2022. 
 
You asked the Plan to pay for the office visit. You say that this was the only provider available. 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 office visit provided 
on August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that the enrollee has Addison's disease with 
episodes of hypoglycemia causing the enrollee to have seizures. The Plan denied your request. The Plan says a 
CGM is not covered under Medicare if the enrollee is not on insulin. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Dexcom 
G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (0241U) provided on December 5, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing (0241U) 
provided on December 5, 2022.