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

 
We decided that the Plan does not have to pay for microsurgical techniques (69990) provided on January 15, 
2022. 
 
  You asked the Plan to pay for microsurgical techniques (69990). You say that these codes are not included in 
each other and are not bundled together. You say that CPT code 69990 should be reprocessed for payment. The 
Plan denied your request. The Plan says procedure code 69990 is an add on code that was billed without 
primary procedure code. 
 
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 69990 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for microsurgical techniques (69990) provided on January 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breath hydrogen or methane test (91065). 
 
You asked the Plan to pre-approve breath hydrogen or methane test. You say that this test is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage of this service are not met. 
 
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 breath hydrogen or methane test. Our 
reviewer says that the Medicare criteria for coverage of this service are not met. Our physician reviewer found 
the enrollee's record does not support undue concern for small intestinal bacterial overgrowth (SIBO), gut 
dysmotility, obstruction, malabsorption or maldigestion. The enrollee's response to simple diet exclusions has 
not been provided in the record. The request for lactulose breath testing is premature in the clinical evaluation 
of this enrollee and is not medically necessary or appropriate at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of breath hydrogen or methane test have not been met. Therefore, we decided that 
the Plan does not have to pre-approve breath hydrogen or methane test (91065).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically 
necessary care can be provided in a different 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve diagnostic MBBs. You say that these injections are medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the requested diagnostic MBBs are subject to the 
criteria listed in the Medicare rule 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 diagnostic MBBs. Our reviewer says 
that the requested diagnostic MBBs are not medically reasonable and necessary. Our physician reviewer found 
this patient has multiple other probable pain generators. Therefore, the request does not meet the criteria of the LCD and 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 diagnostic MBBs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve diagnostic medial branch blocks (MBBs).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and the claim should be 
paid. 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 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 provided on April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and the claim should be 
paid. 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 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 provided on April 16, 2021.
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 you had a heart attack and do not have a lot of staff 
at the hospital. You say that you can feed yourself but need strength to get back home. The Plan denied your 
request. The Plan says you do not meet the criteria for approval of IRF. 
 
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 you were admitted to an acute hospital on 5/28/22. There are no complex nursing 
or rehabilitation needs. While you have a need for physical or occupational therapy, there is no documentation 
of a need for an intensive rehabilitation program. While you may benefit from continued physical and 
occupational therapy, your rehabilitation needs can be safely provided in a lower intensity and alternate setting 
such as in a skilled nursing facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 17, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the bill should have been paid by 
the Plan. The Plan denied your request. The Plan says the proper copayment was applied for the out-of-network 
provider. 
 
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 $40 
copayment for each out-of-network Medicare-covered primary care doctor visit.  
 
  You have been asked to pay a $40 copayment for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctors office visits 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 an office visit provided on September 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for catheter placement in coronary artery(s) for coronary 
angiography (93461). 
 
You asked the Plan to pay for catheter placement for coronary angiography. You say that this service is 
medically necessary. The Plan denied your request. The Plan says the requested service is not medically 
necessary. The enrollee did not mention angina equivalent symptoms and had a normal cardiac exam. 
 
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 catheter placement for coronary 
angiography. 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 had cardiac catheterization in March 
2022, which showed non-hemodynamically significant disease in the left main coronary artery (40%) and left 
anterior descending artery (60%) with fractional flow reverse of 0.83; the right coronary artery showed 
minimal disease. A subsequent office visit indicated no significant change in clinical symptoms or physical 
findings. Guidelines do not support a need for repeat cardiac catheterization in this setting. As a result, at this 
time cardiac catheterization would not be considered medically appropriate and necessary 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 catheter placement for coronary angiography have not been met. Therefore, we 
decided that the Plan does not have to pay for catheter placement in coronary artery(s) for coronary 
angiography (93461).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic radiology services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve diagnostic radiology services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and it was determined these services can be received in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
diagnostic radiology services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve uvulopalatopharyngoplasty (42145). 
 
You asked the Plan to pre-approve the procedure. You say that you would like to resubmit the clinical for the 
enrollee to have a procedure that will be done in your office. The Plan denied your request. The Plan says the 
records do not support that the enrollee meets the criteria for the requested uvulopalatopharyngoplasty. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the record indicates that the enrollee has gastroesophageal reflux. A home sleep 
study indicates a respiratory disturbance index of less than 15. The elements of the coverage criteria are not 
satisfied and the requested service is not recommended. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve uvulopalatopharyngoplasty (42145).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor kit. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 sensor kit. You say that this is medically necessary. The 
Plan denied your request. The Plan says that you do not meet criteria for coverage of a continuous glucose 
monitor. 
 
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 you do not have diabetes mellitus, perform blood glucose testing at least four times per day, 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 Freestyle Libre 2 sensor kit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjustable bed provided on August 6, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the adjustable bed. You say that your health condition and diagnosis warrant the 
need for this durable medical equipment. The Plan denied your request. The Plan says that there was no 
authorization for this purchase. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the adjustable bed provided on August 6, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (K0861) and related accessories and features. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that the requested items are a medical 
necessity for you. The Plan denied your request. The Plan says medical necessity rules for coverage of the 
requested items have not been met. 
 
The Plan follows Medicare rules. The rules say that a Group 3 power wheelchair with multiple power options is 
covered when the criteria listed in the Medicare rules section are met. 
 
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 Group 3 power wheelchair. Our 
reviewer says that the requested items are not medically reasonable and necessary in this case. Our physician 
reviewer found that criteria for a Group 3 power wheelchair are not met. The available documentation does not 
indicate that you have any pressure injuries or require intermittent catheterization of the bladder that would 
necessitate power tilt or recline. 
 
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 Group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (K0861) and 
related accessories and features.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on November 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no evidence to 
support the referring/ordering provider is/was treating the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  
 
We looked at the file and Medicare rules. The records do not show that the genetic testing was ordered by the 
enrollee's treating physician. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
services provided on November 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Supartz FX (J7321). 
 
You asked the Plan to pre-approve Supartz FX. 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 coverage of 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 Supartz FX. 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 drugs Orthovisc, Synvisc, or Synvisc-One before they will approve the requested drug, 
Supartz FX. There is no indication 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 Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Supartz FX (J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of rheumatoid 
arthritis with joint stiffness. The records document she is independent with performing transfers and standing 
up from a chair. There is no indication the rheumatoid arthritis is severely affecting the hip or knee. The seat 
lift mechanism is therefore not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism.