Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pre-approve a Group 2 standard power wheelchair. You say that the requested item is a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for a PMD have not 
been met. 
 
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 does not show that you have a mobility deficit that impairs your participation in MRADLs; that your 
condition cannot be improved by a walker, cane or manual wheelchair; or that you can safely operate the PMD 
being requested. 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 Group 2 standard power wheelchair (K0823).
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 want your father transferred to be closer to 
family. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that there is no evidence that the current facility is unable to provide any necessary 
services. The enrollee can complete his current course of treatment before being discharged 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 70544 is bundled into payment for code 70551.  
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy and foam sclerosant 
injection. 
 You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically 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 the treatment. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provider appears to have seen the patient prior to obtaining the duplex and it is not clear 
if the patient has been reevaluated since the performance of the duplex. The duplex demonstrates thrombus in 
the right great saphenous vein however this thrombus is not mentioned by the provider in creating a plan for 
endovenous ablation of the saphenous vein along with sclerotherapy of its tributary. Additionally, the patient 
has a history of peripheral artery disease, but no pulse examination or other objective assessment of lower 
extremity arterial perfusion is provided in the medical records. In general, thrombosis of the saphenous vein 
and significant peripheral artery disease (PAD) are both contraindications to great saphenous vein ablation, and 
this patient appears to have both. Furthermore, leg pain in a patient with peripheral artery disease cannot be 
attributed to the varicose veins without an assessment of arterial perfusion. 
 
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 treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation therapy and foam sclerosant injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements 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 Hyalgan. Our reviewer says that the 
requirements for coverage of Hyalgan have not been met. Our physician reviewer found the Plan requires a 
trial of Orthovisc or Supartz FX before they will approve the requested drug. In this case, the patient has not 
tried and failed the required drugs. There is no documentation provided indicating that the plans required 
drugs would likely be less effective or 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (84439, 84443) provided on December 29, 
2020. 
 
You asked the Plan to pay for the lab services. You say that you were waiting for diagnosis codes from the 
referring provider. The Plan denied your request. The Plan says the claim was not submitted timely. 
 
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 the lab services was not filed until August 2, 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 the lab services (84439, 84443) provided on December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that 
the enrollee was admitted to the hospital, found to be hypercarbic, and was successfully treated with bilevel 
positive airway pressure (BiPAP). The provided primary source documentation does not contain sufficient 
detailed information in the medical record to justify the treatment selected.  The enrollee could be treated with a BiPAP machine with average volume-assured pressure support (AVAPS) 
capability. The plan has indicated coverage for such a device is available upon request. The elements of the 
coverage criteria are not satisfied. The requested service cannot be 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intrathecal infusion pump. 
 
You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically 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 the pump. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found thatHydromorphone is not Food and Drug Administration (FDA) approved for intrathecal use.  In this 
case, it is clearly documented that the enrollee's pain has responded well to radiofrequency ablation, a spinal cord stimulator, and oral analgesics. The enrollee is known to be allergic to Morphine. There is no 
documentation that the FDA-approved medications (Baclofen and Prialt) have been tried and have failed to 
provide symptom relief. It is not medically reasonable or necessary to trial a pain pump with a non-approved 
drug prior to trying analgesics that are approved for intrathecal use. There is no indication that attempts have 
been made to eliminate physical and/or behavioral abnormalities which may cause an exaggerated reaction to 
pain. The review has determined that the requested intrathecal infusion pump 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 pump have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an intrathecal infusion pump.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that there is no evidence that the enrollee requires services that are not currently 
available. The enrollee can remain at the current acute care hospital until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care needs. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 28, 2022, billed with 
codes 81225 and 81226. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported as 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 
June 28, 2022, billed with codes 81225 and 81226.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography coded 95886, nerve conduction 
studies coded 95908, and the short-latency somatosensory evoked potential study coded 95938 provided on 
October 6, 2021. 
 
You asked the Plan to pay for needle electromyography, nerve conduction studies, and the short-latency 
somatosensory evoked potential study. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the services are not payable as billed. 
 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 95886, 95908, and 95938 are not supported in the medical record. Specifically, these 
services are paid when the facility where the services were rendered are billed. In addition, the services 
rendered were for providing a service for the physician and/or facility. This means payment for the services 
billed are not separately payable. Based on this information, we decided that Medicare rules for coverage of 
needle electromyography, nerve conduction studies, and the short-latency somatosensory evoked potential 
study have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography 
coded 95886, nerve conduction studies coded 95908, and the short-latency somatosensory evoked potential 
study coded 95938 provided on October 6, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 16, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider was not 
certified or eligible to be paid for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
June 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on June 15, 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 procedure code 99292 is not supported. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, the add-on code was not 
billed with a required primary procedure code. 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 pay for the 
critical care services rendered on June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
June 14, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this test was medically necessary and appropriate. 
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 F1CDx testing have 
not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) 
(0037U) testing provided on June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 27, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area 
urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound provided on June 6, 2022. 
 
You asked the Plan to pay for the ultrasound. The Plan denied your request. The Plan says this is not a covered 
screening service. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the ultrasound, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
ultrasound provided on June 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3-level microprocessor knee. 
 
You asked the Plan to pre-approve the knee. You say that this is medically necessary. The Plan denied your 
request. The Plan says a mechanical knee would meet the enrollee's needs. 
 
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 knee. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the coverage criteria are not met, as the records show that the enrollee is not a level 3 ambulator. 
 
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 knee have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a K3-level microprocessor knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care rendered on May 22, 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 services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for an evaluation and management 
service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses 
CPT modifier -57 to indicate that the service resulted in the decision to perform the procedure. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99221 was billed the day before 
major surgery procedure 26530 and was not billed with the -57 modifier to allow for separate payment. 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 pay for the initial hospital care rendered on May 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 13, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 13, 2022.