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

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are appealing the denial for 
intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. The Plan 
denied your request. The Plan says this procedure is considered experimental and investigational as there is 
insufficient evidence of safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at 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 (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance, half leg 
(E0673) and a pneumatic compression device (E0675) provided on August 25, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you disagree with 
the denial and have submitted medical records for review. The Plan denied your request. The Plan says 
pneumatic compression devices are not covered by Medicare when the place of service is an ambulatory 
surgical center. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. We looked at the file and Medicare rules. The records show that you billed with place of service 24, which is 
an ambulatory surgical center. Medicare rules state that for durable medical equipment to be covered, it must 
be appropriate and be needed for use inside the home. Medicare does not consider an ambulatory surgical 
center a home. Based on this information we decided that Medicare rules for coverage of the PCD have not 
been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for 
preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they 
are billed on the claim. Therefore, we decided that the Plan does not have to pay for a segmental gradient 
pressure pneumatic appliance, half leg (E0673) and a pneumatic compression device (E0675) provided on 
August 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard wheelchair and accessories (K0001, E0978, 
E2601, K0195, E2611, E0971). 
 
You asked the Plan to pre-approve a standard wheelchair and accessories. You say that you live in an 
apartment on the sixth floor of a walk up building. You have a personal care assistant (PCA) for sixty-three 
hours per week. You are requesting a standard wheelchair so that your PCA can take you to dialysis 
appointments and take you for walks outside. The Plan denied your request. The Plan says records show that 
you can walk at home using a cane or a walker. The requested wheelchair is not medically necessary because 
you are requesting a wheelchair for your dialysis appointments. The Plan also says that the PCA can arrange to 
have you transported to the van using a wheelchair for your dialysis appointments. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a standard wheelchair and accessories (K0001, E0978, E2601, K0195, E2611, E0971).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the visual field examination provided on  
May 17, 2022. 
 
You asked the Plan to waive the copayment for the visual field examination. You say that this service was part 
of a follow up visit and you should not be responsible for any cost share. The Plan denied your request. The 
Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for a visual field examination.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $33.79 
copayment for a visual field examination. The Plan contract does not clearly say how much enrollees must pay 
for a visual field examination. This means that the Plan did not follow Medicare rules for disclosure of cost 
sharing information. Therefore, we decided that the Plan has to waive the copayment for the visual field 
examination provided on May 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81252, 81251, 81404, 81405) provided on 
July 8, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the denial and are requesting 
reconsideration of payment for genetic testing due to medical necessity. The Plan denied your request. The 
Plan says the request is not medically necessary because records do not show that results of this testing will 
directly impact the enrollees treatment and management. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records do not show a history of medical illness or that the 
requested genetic testing is necessary for the enrollees care or medical condition. The records also show that 
the genetic testing was performed for procreative management. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic testing (81252, 81251, 81404, 81405) provided on July 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the comprehensive metabolic panel (80053), bilirubin, 
direct (82248), glutamyltransferase, gamma (GGT) (82977), thyroid stimulating hormone (TSH) (84443), and 
hemoglobin; glycosylated (A1C) (83036) provided on June 16, 2022. 
 You asked the Plan to pre-approve the comprehensive metabolic panel, bilirubin, GGT, TSH and A1C testing. 
You say that this testing was medically necessary. The Plan denied your request. The Plan says screening tests 
are not covered. 
 
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 comprehensive metabolic panel, bilirubin, GGT, TSH and A1C testing, is 
being 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 pre-approve the comprehensive metabolic panel (80053), 
bilirubin, direct (82248), glutamyltransferase, gamma (GGT) (82977), thyroid stimulating hormone (TSH) 
(84443), and hemoglobin; glycosylated (A1C) (83036) provided on June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician's services for debridement of 
nail(s) provided on November 7, 2022. 
 
You asked the Plan to waive the copayment for the physician's services for debridement of nail(s). You say that 
this visit was for routine foot care and per your Plan's policy, there are 12 visits for routine foot care with a zero 
copay. The Plan denied your request. The Plan says this cost sharing was charged correctly. The claim was 
billed as an illness instead of routine foot care, so the copay applied 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 $30 
copayment for podiatry services.  
 
You have been asked to pay a $30 copayment for the physician's services for debridement of nail(s). This 
service falls within the podiatry services benefit category. The claim was billed with a medical diagnosis of 
tinea unguium. 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 physician's services for debridement of 
nail(s) provided on November 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services rendered on August 9, 2022. 
 You asked the Plan to pay for the services. You say that medical records were provided for review to show that 
the claim was billed appropriately. The Plan denied your request. The Plan says this was 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there was no specific clinical rationale for the obtained drug testing. There was no documentation of 
suspected misuse or use of medications other than those prescribed by the provider. There was no need 
to identify a specific substance or metabolite that is inadequately detected by a presumptive urine drug testing. 
The review has determined that the enrollee did not need these services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services rendered on August 9, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an annual depression screening provided on August 8, 2022. 
 
You asked the Plan to pay for the annual depression screening. The Plan denied your request. The Plan says 
that you are responsible for this amount. We have paid the maximum amount covered by your Plan for this 
service. 
 
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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided proof that an annual depression screening 
had been rendered and billed to the Plan for a previous date of service. Additionally, the Plan has not provided 
a Plan rule or a Medicare rule to substantiate the denial. Therefore, we decided that the Plan has to pay for an 
annual depression screening provided on August 8, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for an office visit. You say that the services at issue have been billed correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that specified HCPCS codes must be reported on 
FQHC and RHC PPS claims. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an office visit have not been met. Specifically, the services at issue in this case were provided by a 
rural health clinic. Code 99214 is not eligible for use by a rural health clinic. Therefore, we decided that the 
Plan does not have to pay for an office visit (99214) billed for date of service August 4, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy. 
 
You asked the Plan to pre-approve psychotherapy. The Plan denied your request. The Plan says medical 
necessity criteria is not met for the requested service because the information given to us shows that the 
symptoms are unclear. The documents submitted contained limited clinical information. The provider did not 
give us progress notes. The provider did not give us a treatment plan. 
 
The Plan must follow Medicare rules. Medicare rules say that to consider coverage and payment for any item 
or service, the information submitted by the supplier or provider must corroborate the documentation in the 
beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of psychotherapy have been met. The 
Plan has not received progress notes or a treatment plan. Therefore, we decided that the Plan does not have to 
pre-approve psychotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the hospital bed, total electric (E0264) provided 
from October 5, 2021, to November 5, 2021. 
 
You asked the Plan to reimburse you for the electric hospital bed. You say that you would like reimbursement 
for the cost of the standard non-electric hospital bed. You also say that this was authorized by your doctor. The 
Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266, 
E0296, and E0297) is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the electric hospital bed have not been met. Since the item in this case is not covered, it is not 
eligible for reimbursement. Therefore, we decided that the Plan does not have to reimburse the rate of a 
standard hospital bed to you for the hospital bed, total electric (E0264) provided from October 5, 2021, to 
November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (72040, G0283, 98940) provided on 
October 20, 2022 to October 27, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that these services were medically necessary 
and should be covered. The Plan denied your request. The Plan says these are not covered services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for chiropractic services (72040, G0283, 98940) provided on October 20, 
2022 to October 27, 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 based on the enrollee's clinical picture, 
providers have determined that the enrollee is stable and suitable for transfer to an LTACH. You say the 
enrollee cannot be adequately cared for at a skilled nursing facility or any other lower level of care. The Plan 
denied your request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight genetic testing (81479) provided on April 29, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that please accept this appeal letter and the attached 
statement of medical necessity and test request form as your request for a retroactive authorization request. The 
Plan denied your request. The Plan says the precertification requirements were not met. Non-emergent services 
with non-contracted providers require prior authorization before services being rendered.  
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing have been met. The 
documentation provided does not include any clinical records from the ordering provider. The records show 
that the Plan made several attempts to obtain clinical records from the ordering provider without success. 
Therefore, we decided that the Plan does not have to pay for GeneSight genetic testing (81479) provided on 
April 29, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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, for 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 September 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (procedure code 99291) rendered on 
September 1, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the enrollee was discharged to home the same day as code 99291 was reported. 
 
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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the review has determined that 
the records do not support the use of CPT 99291 in this case. There was no highly complex medical decision 
making. The services were not needed to prevent further life-threatening deterioration of the patients 
condition. It is not expected that a patient be discharged home the same day as a provider reports CPT 99291. 
 
We looked at this coder's review, the file, and Medicare rules. 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 critical care services (procedure code 99291) rendered on September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71046), abdomen x-ray (74018), 
transportation of portable x-ray equipment and personnel (R0075), and set-up of portable x-ray equipment 
(Q0092) provided on October 7, 2022, by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the x-rays, transportation of portable x-ray equipment and personnel, and set-up 
of portable x-ray equipment. You say that there was no time to obtain authorization for the services rendered. 
You also say that detaining the test could have been life-threatening, because of the enrollee's status at the time 
of service. The Plan denied your request. The Plan says these services were rendered by an OON provider, and 
prior authorization was not obtained. The Plan also says both the referring and rendering providers are OON 
with the Plan. 
 
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 
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 chest x-ray (71046), abdomen x-ray (74018), 
transportation of portable x-ray equipment and personnel (R0075), and set-up of portable x-ray equipment 
(Q0092) provided on October 7, 2022, by an out-of-network (OON) provider.