Persius/hicric huggingface dataset:
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 enrollee. 
The Plan denied your request. The Plan says all services that would be provided in the LTACH are being 
provided already in the current acute care setting already approved. The enrollee can remain in the current 
acute care location until such time no further acute level care is needed. 
 
 
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 patient is not yet stable and 
as it would not be clinically advantageous. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiogram and myocardial strain imaging provided 
on July 8, 2022. We also decided the Plan does not have to pay for myocardial perfusion imaging, tomographic 
(SPECT), Technetium tc-99m sestamibi, a cardiovascular stress test, and a regadenoson injection provided on 
July 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an ultrasound, myocardial strain imaging (SPECT), a cardiovascular stress test 
and a regadenoson injection. You say that you were not aware it was expired, and you cannot afford to pay the 
cost sharing. The Plan denied your request. The Plan says the services listed in the Medical Benefits Chart are 
covered only when you receive your care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an echocardiogram and myocardial strain imaging 
provided on July 8, 2022. We also decided the Plan does not have to pay for myocardial perfusion imaging, 
tomographic (SPECT), Technetium tc-99m sestamibi, a cardiovascular stress test, and a regadenoson injection 
provided on July 12, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-emergent ambulance transportation (A0100). 
 
You asked the Plan to pre-approve the non-emergent ambulance transportation. You say that you need this 
service. The Plan denied your request. The Plan says the request exceeds the mileage limitation for a one-way 
trip. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when non-emergency ground transportation trips are limited to 75 miles, one-way, unless approved by the plan. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the non-emergent ambulance transportation (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Orthovisc (J7234), injection (20610), and fluoroscopic 
guidance for needle placement (77002) provided on April 7, 2022. 
 
You asked the Plan to pay for the Orthovisc injection. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Orthovisc injection. Our reviewer says 
that the Orthovisc injection is not medically necessary. Our physician reviewer found the Orthovisc package 
insert recommends a dosage of once per week (1 week apart) for a total of 3 to 4 injections. The reviewer found 
that the provided documentation indicates that the injection in this case is the fifth of the series. The reviewer 
found there is no literature support establishing the efficacy or safety of a 5th injection of Orthovisc. Therefore, 
the reviewer found that the Orthovisc injection 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 Orthovisc injection have not been met. Therefore, we decided that the Plan 
does not have to pay for the Orthovisc (J7234), injection (20610), and fluoroscopic guidance for needle 
placement (77002) provided on April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360, 88341, 88342 and 88381 billed for 
date of service January 24, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360, 88341, 88342 and 88381. You say that these services 
were reported correctly. 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 inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360, 88341, 88342 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360, 
88341, 88342 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88360, 88341, 88342 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88360, 88341, 88342 and 88381 billed for date of service January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2022, billed with 
codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81295, 81298, 81301, 81317, 81401, 81401, 81194, 
and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. 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 
March 8, 2022, billed with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81295, 81298, 81301, 
81317, 81401, 81401, 81194, and 81309.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration. 
 
You asked the Plan to pre-approve bone marrow aspiration. You say that the records provided support the need 
for the services which remain in dispute. The Plan denied your request. The Plan says the clinical value and 
effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the 
peer-reviewed literature. 
 
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 bone marrow aspiration. Our reviewer 
says that bone marrow aspiration is not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspiration is considered experimental, and more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service June 2, 2022. 
 
You asked the Plan to pay for procedure code 11721. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 11721 is bundled into 
payment for code 11056. 
 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 11721 
is a column II code to column I code 11056. 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 11721 billed for date of service June 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is 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 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 based on the medical records provided there is no documentation that daily 
skilled services are required.  The provided records do not document a significant decline in the enrollees 
functional status to necessitate daily inpatient skilled therapy services. There is no documentation that the 
enrollee requires the services on an inpatient basis, only in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. Records do not 
support that services in an assisted living facility with home health care or in a long-term care facility on a part 
time basis are not appropriate in this case. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (E1012, E2311, E2377, E2313, 
E2361 x2, E1007, E1028, E0955). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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.  
 
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 power wheelchair. Our reviewer 
says that the power wheelchair is not medically necessary. Our physician reviewer found the enrollee has 
household mobility using a cane. She does not require a power wheelchair to complete activities of daily living. 
 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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair (E1012, E2311, E2377, E2313, E2361 x2, E1007, E1028, 
E0955).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88306, 88342 and 88341 billed for date of 
service June 28, 2022. 
 
You asked the Plan to pay for procedure codes 88306, 88342 and 88341. You say that this claim should be 
paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 17, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure codes 88306, 88342 and 88341 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 88306, 88342 
and 88341 billed for date of service June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power option 
(K0856, E2361, E1002, E2620). 
 
You asked the Plan to pre-approve the power wheelchair. You say that this type of power wheelchair is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair is covered when 
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 power wheelchair. Our reviewer 
says that this type of power wheelchair is not medically necessary. Our physician reviewer found the enrollee is not a high risk for skin breakdown as she has been in a wheelchair for at least 4 years with no breakdown. 
Records show that the enrollee does not require a special controller. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 3 power wheelchair with a single power option (K0856, E2361, E1002, 
E2620).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Signatera genetic testing services. 
 
You asked the Plan to pre-approve Signatera genetic testing services. You say that the records provided support 
the need for the requested testing. The Plan denied your request. The Plan says the records do not show that 
you are being treated with immune-checkpoint inhibitor therapy. 
 
The Plan follows Medicare rules. Medicare rules say that Signatera genetic testing services are covered for 
certain indications. 
 
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 Signatera genetic testing services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation 
does not indicate that you have colon cancer or are being treated with immune checkpoint inhibitor therapy. 
Signatera genetic testing services are not considered medically reasonable and necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Signatera genetic testing services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Signatera genetic testing services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (U0003) provided on December 21, 2020. 
 
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 Original Medicare is liable for payment for this service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for lab services (U0003) provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from December 17, 2021, to 
December 22, 2021. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says this type of provider 
is not part of the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist (MFT) 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 Marriage Family Therapist 
(MFT). Medicare says that a Marriage Family Therapist (MFT) is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from  
December 17, 2021, to December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that manual wheelchairs are only covered under certain 
medical indications.  
 
The file shows that a manual wheelchair (K0005) with related accessories was requested. 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 requested services. Our physician reviewer found 
that you are mobile in the home. You do not require the requested device to complete mobility associated 
activities of daily living in the home. Therefore, the request is not medically necessary.  
 
The records show that your previous wheelchair was returned. This was shown by the pickup ticket record in 
the case file. A new wheelchair is not contingent upon a monetary reimbursement. We looked at the physician's 
review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
manual wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 86077. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service June 7, 2022.