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

 
We decided that the Plan does not have to pay for the Genesight testing (81479) provided on September 19, 
2022. 
 
You asked the Plan to pay for the Genesight testing. You say that the provided Genesight testing was medically 
necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the provided 
Genesight testing provided. 
 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 the Genesight testing. Our reviewer says that 
the enrollee did not meet criteria for the provided Genesight testing provided. Our physician reviewer found the 
documentation indicates that the enrollee has a history of anxiety which was reportedly "getting better" at 
the time the genomics testing was ordered. There is no mention in the medical record of any family history or 
genetic concerns. There is no documentation that the member had tried multiple psychiatric medications 
without success. The medical record contains no documentation that the member had failed to respond to 
medication trials, nor that she had experienced worrisome side effects from any medications she has taken for 
anxiety. The review has determined that the enrollee did not meet the LCD criteria for the provided Genesight 
testing. 
 
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 Genesight testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Genesight testing (81479) provided on September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service October 25, 
2022. 
 You asked the Plan to pay for procedure code 85060. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 8 for CPT code 85060. This means there is only a 
professional component for the CPT code. In this case, an appropriate modifier to indicate the professional 
component has not been billed with CPT code 85060. Based on this information, we decided that Medicare 
rules for coverage of procedure code 85060 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 85060 billed for date of service October 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Medtronic Solera Adaptix. 
 
You asked the Plan to pre-approve Medtronic Solera Adaptix. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
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 Medtronic Solera Adaptix. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is limited published, large-scale, long-term, peer-reviewed literature 
that shows the requested device to be an effective and/or safe treatment for the enrollee's pathology. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Medtronic Solera Adaptix have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the use of Medtronic Solera Adaptix.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service October 20, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. The Plan denied your request. The Plan says code 99153 
is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service October 20, 2022, billed 
with code 99153.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing services. 
 
You asked the Plan to pre-approve skilled nursing services. You say that you need continued skilled nursing 
services, so you do not end up in the hospital. The Plan denied your request. The Plan says the requested 
services have not been ordered or certified by a physician. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We looked at the file and Medicare rules. The record does not show your physician ordered or certified 
additional skilled nursing services. Therefore, we decided that the Plan does not have to pre-approve skilled 
nursing services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) myelogram of the lumbar 
spine. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the denial of the prior approval was correct. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that the pain 
management specialist states the patient had magnetic resonance imaging (MRI) of the lumbar spine which did 
not explain the symptoms. There is no report of this MRI in the records. The results of this MRI would need to 
be provided to approve the CT scan. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) myelogram of the lumbar spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75710 and 75625 billed for date of service 
October 13, 2022. 
 You asked the Plan to pay for procedure codes 75710 and 75625. You say that these services were reported 
correctly and are supported in the medical records. The Plan denied your request. The Plan says these services 
are not supported in the medical record. 
 
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 75625 is angiography, abdominal, by serialography, 
radiological supervision and interpretation. In addition, we have confirmed that code 75710 is a column II code 
to column I code 37229; however, 75710 was billed with a modifier. 
 
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 codes 75710 and 75625. Our reviewer says that 
these services are not supported in the medical records. Our reviewer found that the operative report does not 
describe an angiography, abdominal, by serialography which meets the CPT code definition for code 75625. A 
local anesthetic is applied over the common femoral artery. The artery is percutaneously punctured with a 
needle and a guidewire is fed through the artery into the abdominal aorta. A catheter is threaded over the 
guidewire to the point of study and the guidewire is removed. Contrast medium is injected, and films are taken 
by serialography, producing a series of individual x-ray films. This procedure was not found in the 
documentation provided; therefore, code 75625 is not supported in this case.  
 
In addition, the operative report describes an intervention in lower extremity, with radiological supervision and 
interpretation. However, when an intervention is performed, angiograms and/or venograms would be inclusive 
to the intervention procedure. There is no evidence to show that 75710 was separate and distinct from the 
intervention procedure; therefore, the reporting of 75710 is also not supported in this case. 
 
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 codes 75710 and 75625 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 75710 and 75625 billed for date of service October 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) services. 
 
You asked the Plan to pre-approve PBRT services. You say that the enrollee has a life-threatening diagnosis of 
prostate cancer and PBRT is medically necessary. You say that conventional treatment techniques are 
indicative of low quality of life. The Plan denied your request. The Plan says PBRT is not the standard of care 
for prostate cancer. 
 
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 PBRT services. Our reviewer says that 
PBRT is not considered medically reasonable and necessary in this case. Our physician reviewer found any 
potential benefit or detriment of proton therapy over standard intensity-modulated radiation therapy (IMRT) is 
an investigational question. Other treatment approaches are also highly effective and well tolerated. Thus, 
whether proton therapy affords a benefit over other standard approaches for prostate cancer is an area of 
investigation and remains controversial.  Particularly with the use of the SpaceOAR hydrogel spacer, the risk of 
gastrointestinal/rectal toxicity is low (since the rectum is pushed away from the prostate) such it is even more 
unlikely that there would be a potential benefit from proton therapy.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy (PBRT) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
25, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service September 25, 
2022.
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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the request for an LTACH 
admission is denied as not medically necessary. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Guide strips (A4253). 
 
You asked the Plan to pre-approve the strips. You say that the items are necessary. The Plan denied your 
request. The Plan says there was no documentation provided to support the medical necessity of a non-
LifeScan product. 
 
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 strips. Our physician reviewer 
found there is no reason given why the OneTouch strips and meter would not suffice; if there is a reason the 
enrollee needs the Accu-Chek and could not use the OneTouch, then this information should be provided and 
the case re-reviewed. 
 
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 strips have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Accu-Chek Guide strips (A4253).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered on September 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. 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 the place of service reported must be correct. 
 
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 an outpatient place of 
service, even though the enrollee was in an inpatient confinement at the time of service. Therefore, we decided 
that the Plan does not have to pay for laboratory services rendered on September 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity arterial revascularization services. 
 
You asked the Plan to pre-approve lower extremity arterial revascularization services. You say that the 
requested services are medically necessary to treat the enrollee's severely symptomatic varicose veins and 
venous insufficiency. You say that failure to undergo this requested therapy would result in inadequate 
treatment and will have serious consequences to the patient. The Plan denied your request. The Plan says the 
requested revascularization procedures are not medically necessary at this time. 
 
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 lower extremity arterial 
revascularization services. Our reviewer says that lower extremity arterial revascularization service are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the medical record 
documents normal pedal pulses bilaterally. Additionally, there is no documentation in the assessment and plan 
that any arterial intervention is being considered. The conclusion by the provider was that no intervention was 
needed and that a conservative approach would be applied. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity arterial revascularization services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lower extremity arterial revascularization 
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitoring supplies (K0553) provided on 
October 25, 2022. 
 
You asked the Plan to pay for continuous glucose monitoring supplies. You say that this is supported in the 
records. The Plan denied your request. The Plan says the submitted proof of delivery is invalid. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The submitted proof 
of delivery shows a shipping date and a delivery date prior to the billed date of service. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for continuous glucose monitoring supplies (K0553) provided on October 25, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CGM supplies (CPT code A4239). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the enrollee should be able to continue 
to use a CGM due to the enrollee's worsening dementia even though the enrollee only uses one dose of insulin 
per day. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 enrollee is not insulin treated with multiple (three or more) daily 
administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump with frequent adjustments 
based on the enrollee's blood sugar readings. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the CGM supplies (CPT code A4239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the enrollee is eligible for a CGM 
because they take insulin twice a day. The Plan denied your request. The Plan says the enrollee does not require 
insulin three or more times daily. 
 
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 CGM and 
supplies.
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 live alone and in need of rehabilitation due to 
weakness and unsteady on your feet and possible fall risk. The Plan denied your request. The Plan says your 
rehabilitation needs are not complex, and an intensive team is not needed. 
 
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.