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

 
We decided that the Plan does not have to pay for the surgical services (25295) provided on April 2, 2022. 
 
You asked the Plan to pay for procedure code 25295. You say that the medical records support the billing of 
code 25295. The Plan denied your request. The Plan says the medical records do not support the billing of code 
25295. 
 
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, the CPT Code Manual definition of code 25295 is Tenolysis, flexor or extensor tendon, forearm 
and/or wrist, single, each tendon. 
 
We asked our coder 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 procedure code 25295. Our reviewer says that the medical 
records do not support the billing of code 25295. Our reviewer found the documentation submitted was 
reviewed, and the medical records do not support the billing of code 25295. The operative report documents an 
open reduction and internal fixation of the left distal radius, as well as tenolysis of the left brachioradialis with 
partial release for diagnosis of Intra-articular displaced fracture of the left distal radius and ulna fracture.  In this case, tenolysis would be inclusive to the fracture treatment, as procedure were performed same anatomical 
site as well as for the same diagnosis.  Therefore, reporting CPT 25295 separately from CPT 25609 cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 25295 have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services (25295) provided on April 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 1, 2022 billed with 
codes 81272, 81210, 81235, and 81206. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not billed correctly. 
 
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 1, 2022 billed with codes 81272, 81210, 81235, and 81206.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says based on the clinical information received, the enrollee 
does not meet the guidelines for long-term acute care services. They can safely receive this care in the current 
hospital setting. 
 
 
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 transfer to the LTACH is not medically necessary as the enrollee is not yet stable, has 
not underwent sufficient weaning attempts, and as it would not be clinically advantageous at this time. 
Completion of treatment at the current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF services to gain the strength to be 
able to return home. The Plan denied your request. The Plan says the enrollee does not require daily skilled 
therapy services on an inpatient basis. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not required. There is no documentation that you require 
services on an inpatient basis, only in a skilled nursing facility setting. Daily skilled services are not shown to 
be required to establish a maintenance program or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the pain is around your lower back, 
and it hurts so bad you want to scream. The Plan denied your request. The Plan says your request is not 
medically necessary because there is little evidence in the medical literature to suggest that this is an 
appropriate procedure for your back pain. The Plan states it is not an accepted standard of medical practice for 
the diagnosis or treatment of back pain. The Plan states it is considered experimental and 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 there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested intracept intraosseous 
basivertebral nerve ablation at L4 and L5 vertebral levels, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code 64628).
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 documentation does not support necessity for admission to an IRF as there is no 
medical complexity or nursing needs. While the enrollee may benefit from continued physical and occupational therapy, the enrollee's rehabilitation needs can be provided in a lower intensity and alternate setting such as in a 
skilled nursing facility or in-home with services and family support. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) system. 
 
You asked the Plan to pre-approve a CGM. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
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. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for crutches provided on April 11, 2022. 
 
You asked the Plan to pay more for crutches. You say that you should be reimbursed more for this. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
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 20% 
coinsurance for crutches.  
 
You have been asked to pay $14.35 for crutches. The Plans allowance was $71.76; you were reimbursed 
$57.41. $71.76 - $57.41 = $14.35 This item/service falls within the durable medical equipment (DME) and 
related supplies 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 pay more for crutches provided on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a digital hearing aid provided on March 10, 2022, by an out-
of-network provider. 
 
You asked the Plan to pay for a digital hearing aid. You say that in your copy of the 2022 EOC, Section 3.2 it 
states that "you can choose to receive care from out-of-network provider. However, if you use an out-of-
network provider, your share of the costs for your covered services may be higher." You also say that you are 
familiar with and accept that premise, but it does not mean that there is no coverage for out-of-network 
providers. The Plan denied your request. The Plan says hearing aids purchased outside of the Plan network are 
not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased inside the Plan network.  
 
 
  We looked at the file, and the Plan's rules. The record shows the Plan clearly states in the contract that hearing 
aids purchased outside the network are not covered. The record also shows that hearing aids were purchased 
outside the Plan network. Based on this information, we decided that the Plan's rules for coverage of a digital 
hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for a digital hearing 
aid provided on March 10, 2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV) scooter (K0800). 
 
You asked the Plan to pre-approve a POV scooter. You say that you need a POV to access the community. You 
need assistance and are requesting reconsideration for the denial. The Plan denied your request. The Plan says 
you asked for a POV to access the community. You had a physical therapy (PT) assessment. You are able to 
walk in your home without a device. You walk with a cane outdoors. You are able to drive your own car to 
appointments. A physical therapist ordered a rollator which allows you to sit and rest when you are walking. 
You must meet the above criteria to be approved for a POV. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. The records 
show you are able to walk in your home without a device and you walk with a cane outdoors. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (POV) scooter (K0800).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from January 25, 2022, to February 
21, 2022. 
 
You asked the Plan to pay for the services provided. You say that you were not informed of a payer change. 
The Plan denied your request. The Plan says that a RAP claim was not submitted until March 30, 2022. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan denied as a RAP claim was not submitted timely. This rule was in effect for services provided in 
2021. However, the dates of service were provided in 2022. HHAs shall no longer submit Requests for 
Anticipated Payment (RAPS) for any HH period of care with a From date on or after January 1, 2022. The Plan 
has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request.  Therefore, we decided that the Plan has to pay for the home health services provided from 
January 25, 2022, to February 21, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osteogenesis stimulator, low intensity ultrasound, 
non-invasive (CPT code E0760). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says they do not have evidence that the enrollee has a fracture, they do not have evidence that 
the enrollee has a fracture that is not healing, and the enrollee does not have x-rays 90 days apart that shows a 
nonunion of a fracture. 
 
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 DME. Our physician reviewer 
found there is no documentation that the osteogenesis stimulator at issue in this case meets all of the LCD 
criteria for medically reasonable and necessary for the enrollee. Provided records do not document nonunion of 
a fracture documented by a minimum of two sets of radiographs obtained prior to starting treatment with the 
osteogenesis stimulator, separated by a minimum of 90 days or failed fusion of a joint other than in the spine 
where a minimum of nine months has elapsed since the last surgery or a congenital pseudarthrosis as required by the LCD. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the osteogenesis stimulator, low intensity ultrasound, non-invasive (CPT code E0760).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Feraheme (CPT code Q0138). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee is fatigued but not symptomatic. 
The Plan denied your request. The Plan says that the medication is not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the medication. Our physician reviewer 
found per package insert: Feraheme is an iron replacement product indicated for the treatment of iron 
deficiency anemia (IDA) in adult patients: who have intolerance to oral iron or have had unsatisfactory 
response to oral iron (1). 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve Feraheme (CPT code Q0138).  
 
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 urine PCR (polymerase chain reaction) panel (87481, 
87500, 87640, 87641, 87651, 87653 and 87798) provided on April 27, 2022. 
 
You asked the Plan to pay for the urine PCR panel. You say that these services were medically necessary and 
were ordered by the enrollee's physician. The Plan denied your request. The Plan says this panel was not billed 
in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR panel have not been met. Specifically, the records show that a single panel was 
ordered and performed, but this service was billed by reporting individual components. Therefore, we decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel (87481, 87500, 87640, 
87641, 87651, 87653 and 87798) provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis (SO), figure of eight design abduction 
restrainer, canvas and webbing, prefabricated, off-the-shelf (L3660) provided on March 10, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the shoulder orthosis. You say that you assumed when your primary care 
physician refers you to another doctor then they are giving authority to them for whatever has to be done. The 
Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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. Also, under Medicare rules this device is not a covered benefit because it is not a rigid or 
semi-rigid device and does not come within the scope of a brace. 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 shoulder 
orthosis (SO), figure of eight design abduction restrainer, canvas and webbing, prefabricated, off-the-shelf 
(L3660) provided on March 10, 2022 by an out-of-network (OON) provider.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 have minimal change in your chronic condition and have quite modest 
rehabilitation needs. You do not require intensive rehabilitation, frequent physiatry oversight, or highly coordinated interdisciplinary 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.