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

 
We decided that the Plan does not have to pay for lab services provided on July 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve miscellaneous durable medical equipment, wheelchair 
ramp (E1399). 
 
You asked the Plan to pre-approve the wheelchair ramp. You say that you are appealing the denial of because 
you feel that the ramp is medically necessary and if there was a fire in the house you would not be able to get 
out. The Plan denied your request. The Plan says this item is not primarily medical in nature and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve miscellaneous durable medical equipment, wheelchair ramp 
(E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronic Acid Injections (20610). 
 
You asked the Plan to pre-approve the injections. You say that this service 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 Hyaluronic Acid Injections are 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 injections. Our reviewer says that 
the injections are not medically necessary. Our physician reviewer found there is no documentation of any 
imaging of the knee and no notation of prior conservative treatments. The enrollee is on medical therapy but 
also has conditions of neck and back pain.  
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyaluronic Acid Injections (20610).
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 are wanting services for a week for further 
therapy, so you do not lose all function in your leg. The Plan denied your request. The Plan says The enrollee's 
records show that it is not reasonable to expect that they will be able to fully benefit inpatient rehabilitation 
facility (IRF). The enrollee has declined to participate consistently with therapy in the hospital, as recently as 3 
days ago. It is not reasonable to expect that the enrollee will be willing to fully participate in 3 hours of therapy 
5 days a week or in 15 hours of therapy a week. Your doctor recommends outpatient follow up for your 
neurologic issues. The services you need can be provided safely in other settings, for example, a skilled nursing 
facility (SNF), home with home health services or home with outpatient therapy. 
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
congestive heart failure and bronchitis. Medical problems are stable. There are no complex nursing or 
rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) billed for date of service 
November 28, 2021. 
 
You asked the Plan to pay for critical care. You say that this service was reported appropriately. The Plan 
denied your request. The Plan says this service is 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records which support 
that an hour of critical care services were for other dates of service. The records for November 28, 2021, do not 
support that 30-74 minutes of critical care were provided, and the charge ticket included with the medical 
records describes the service(s) provided on this date as "subsequent inpatient care" which is reported with a different code. Based on this information, we decided that Medicare rules for coverage of critical care have not 
been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) billed for 
date of service November 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation. You say that the enrollee needs this service. 
The Plan denied your request. The Plan says the requested procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that treatment for lower urinary tract symptoms 
(LUTS)/benign prostatic hyperplasia (BPH) treatment will be considered reasonable and necessary when 
performed once in patients that meet all of the criteria. 
 
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 transurethral waterjet ablation. Our reviewer says that transurethral waterjet ablation of prostate is not medically necessary. Our physician reviewer 
found the provided documentation does not indicate that the enrollee has an International Prostate Symptom 
Score (IPSS) of less than or equal to 12, and a maximum urinary flow rate (Qmax) of equal to or more than 15 
mL/s (voided volume greater than 125 cc). Therefore, the reviewer found that the requested procedure 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 transurethral waterjet ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 14-day sensor kit. 
 
You asked the Plan to pre-approve the FreeStyle Libre 14-day sensor kit. You say that the enrollee is a Type 2 
uncontrolled diabetic who is on insulin at least 2 times day and needs to check blood glucose level multiple 
times per day. The Plan denied your request. The Plan says the enrollee is on insulin twice a day and does not 
meet all of the Medicare criteria. 
 
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the FreeStyle Libre 14-day sensor kit have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle Libre 14-day sensor 
kit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that endovenous ablation is covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not support that the 
enrollee is having pain that is interfering with activities. There is no documentation of edema. There is no 
evidence that concerted efforts at a conservative approach were tried and failed. The criteria for coverage are 
not met and the endovenous ablation is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower-extremity revascularization procedures. 
 
You asked the Plan to pre-approve lower-extremity revascularization. You say that the requested services are a 
medical necessity for you. The Plan denied your request. The Plan says the request 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 lower-extremity revascularization. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that you have evidence of lower extremity arterial disease, but the evidence does 
not confirm the presence of severe arterial stenosis, nor is there evidence that the claudication symptoms are of 
sufficient severity that they interfere with activities of daily living. Moreover, the records do not show that 
guideline-directed medical therapy, such as a program of structured exercise, has been carried out. 
 
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 revascularization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve lower-extremity revascularization procedures.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64450). 
 
You asked the Plan to pre-approve the nerve block. You say that you are in a lot of pain. You say that you have 
many medical issues. You also say that you feel this treatment can help you to manage your pain. The Plan 
denied your request. The Plan says the requested nerve block 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 nerve block. Our reviewer says that 
the requested genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested the genicular nerve block is considered experimental or investigational 
in nature. Therefore, the reviewer found that the requested block is not reasonable or medically 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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block (64450).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483) and 
each additional level (64484). 
 
You asked the Plan to pre-approve the injections. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 injections. Our physician reviewer 
found the request for the injections are not medically necessary because the records show that the enrollee does 
not have post-laminectomy syndrome, acute herpes zoster, or image-based diagnostic testing that supports 
radicular pain due to disc herniation, osteophyte or osteophyte complexes, or severe degenerative disc disease 
producing foraminal or central spinal stenosis. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging 
guidance (fluoroscopy or CT), lumbar or sacral, single level (64483) and each additional level (64484).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Immune Globulin (Hizentra). 
 
You asked the Plan to pre-approve Hizentra. The Plan denied your request. The Plan says this is not a buy and 
bill medication. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Immune Globulin (Hizentra).  
 
Benefits for Hizentra may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit provided on July 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a physician visit. You say that the assisted living facility is responsible to obtain 
prior authorization. The Plan denied your request. The Plan says services can be obtained from an in-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 a physician visit provided on July 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided August 1, 2022. 
 
You asked the Plan to pay for the orthosis. You say that the medical records provided support the necessity of 
the services in dispute. The Plan denied your request. The Plan says The medical records due not indicate 
intention or need for this DME.  
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the medical records due not indicate intention or need for this DME. The review 
has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare 
coverage. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (L0650) provided August 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression boots (E1399). 
 
You asked the Plan to pre-approve the compression boots. You say that this item is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve compression boots (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that acupuncture treatment is medically necessary. 
The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
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 these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that the documentation 
provided does not support that you have had chronic low back pain lasting 12 or more weeks.    
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve acupuncture treatments.
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 
August 11, 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 August 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Percocet tablet. 
 
You asked the Plan to pre-approve Percocet. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Percocet 
tablet.  
 
  Benefits for Percocet may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.