Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 26, 2022 to 
February 24, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the home health services were 
medically necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 26, 2022 to 
February 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five Hyaluronan injections. 
 
You asked the Plan to pre-approve five Hyaluronan injections. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Hyaluronan injections are only 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 five Hyaluronan injections. Our 
reviewer says that the documentation does not support that the requested injections are medically reasonable or 
necessary. Our physician reviewer found the enrollee had hyaluronate injections in both knees in April 2022 
and as well as trying other treatments that have been unsuccessful in alleviating your symptoms. On September 
26, 2022 your physician documented, "had monovisc injections in April and no relief". The LCD specifically 
states that there has to be improvement from the prior injections. This is clearly not the case here and therefore, 
the request is deemed not medically reasonable and 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 five Hyaluronan injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve five Hyaluronan injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 19, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. 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 March 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 and presumptive drug 
testing (code 80307) for date(s) of service July 12, 2022. 
 You asked the Plan to pay for code 83789. You say that these services were medically necessary and should be 
paid. The Plan denied your request. The Plan says code 83789 is not separately payable. Code 80307 is not 
supported in the medical records provided, as there are no results of the screening test. 
 
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. Medicare rules also 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 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. In addition, we have decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of code 80307 have been met. Specifically, the record does not include the 
results of the presumptive drug screening. Without this information, we cannot verify that this service was 
performed as billed. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 and presumptive drug testing (code 80307) for date(s) of service July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14-Day Sensors (CPT code K0553). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. 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 documentation does not show that you use insulin to treat your 
diabetes. There is no evidence you use insulin. Based on this information, we decided that Medicare rules for 
coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Freestyle Libre 14-Day Sensors (CPT code K0553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (procedure code G0483) provided to the enrollee on July 26, 2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the medical records do not show screening test results which are positive or inconsistent with 
prescription medications, dosing schedules, or history and expected results. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the review has determined that the records did not support that 22 or more drug classes were needed 
to be tested in this case. The medical record sent by the provider shows a definitive UDT panel for multiple 
drug classes was performed but does not show screening test results which are positive or inconsistent with 
prescription medications, dosing schedules, or history and expected results. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for definitive urine drug testing (UDT) for 22 or more drug classes (procedure code G0483) provided to 
the enrollee on July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM and related supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested items are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage of CGMs and related 
supplies 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 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 and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a CGM and related supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 you will benefit from IRF level of physical therapy (PT) and occupational therapy 
(OT) and your rehabilitation needs cannot be safely met in an alternate and low intensity setting such as in a 
skilled nursing facility (SNF). 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SPRINT PNS system. 
 
You asked the Plan to pre-approve SPRINT PNS system. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are 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 SPRINT PNS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has right knee pain. X-rays show mild osteoarthritic injuries. The 
enrollee had a steroid injection and physical therapy and the enrollees pain was not much improved. The 
enrollee cannot take anti-inflammatory medicine due to kidney disease. A recent magnetic resonance imaging 
(MRI) of right knee shows partial thickness tear of the anterior cruciate ligament (ACL) and degenerative 
meniscus tear. The enrollee underwent ultrasound guided right saphenous nerve hydrodissection injection 
procedure without sustained pain relief. The use of PNS systems for pain control of an osteoarthritic knee is 
unproven and experimental. Therefore, the enrollee does not meet criteria for the requested 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 SPRINT PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve SPRINT PNS system.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 21, 2022, to 
February 16, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the notice of admission was 
submitted. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We looked at the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from January 21, 2022, to February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight testing (81479) provided on November 10, 2021. You asked the Plan to pay for GeneSight testing. You say that this test is covered by Medicare and should be 
paid. The Plan denied your request. The Plan says there are insufficient records to process this claim. 
 
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 GeneSight testing have been met. 
Specifically, the physician order included in the provided records is not signed. There is also no clear 
documentation, including medical records or progress notes, from the enrollee's treating physician indicating 
the intent to have this testing performed and showing that the enrollee meets the criteria for medical necessity 
for this test. Therefore, we decided that the Plan does not have to pay for GeneSight testing (81479) provided 
on November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 22, 2021, billed 
with codes 81401, 81403, 81404, 81405, 81406, 81407, 81408 and 81479. 
 
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 
September 22, 2021, billed with codes 81401, 81403, 81404, 81405, 81406, 81407, 81408 and 81479.
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. 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 been met. Therefore, we 
decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that additional transportation 
services are medically necessary. The Plan denied your request. The Plan says the benefit for routine 
transportation has been exhausted. 
 
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 a maximum of 12 one-way routine transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about your condition you do not meet all the requirements. 
 
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. You were admitted for 
surgical repair of a femur fracture.  Medical problems are stable.  There are no complex nursing or rehabilitation needs. While the medical records support a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 16, 2022, billed with 
codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194, and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically 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 16, 2022, billed with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 
81401, 81194, and 81309.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - Porcelain fused to high noble metal Tooth # 3, 
4, 6, 11, 14 (D2750), complete denture -mandibular (Lower Arch) (D5120) and maxillary partial denture, resin 
base (including retentive/clasping materials, rests, and teeth) (D5211). 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of the 
requested services. The Plan denied your request. The Plan says there is not enough missing tooth to necessitate 
a crown. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
services when the services are medically necessary and reasonable. Complete denture -mandibular (Lower 
Arch) (D5120) and maxillary partial denture, resin base (including retentive/clasping materials, rests, and teeth) 
(D5211) are not covered under the Plans dental benefits. 
 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 dental services. Our physician reviewer 
found the documentation provided does not meet the criteria for coverage for crown restorations (D2750) for 
teeth #'s 3, 4, 6, 11 and 14. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Crown - Porcelain fused to high noble metal Tooth # 3, 4, 6, 11, 14 (D2750), Complete 
denture -mandibular (Lower Arch) (D5120) and Maxillary partial denture, resin base (including 
retentive/clasping materials, rests, and teeth) (D5211).