Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic mammography (77066), a diagnostic digital 
breast tomosynthesis (G0279) and an ultrasound, breast, unilateral (76642) provided on June 9, 2022, by an 
out-of-network (OON) provider. 
 
 
 
 
 You asked the Plan to pay for imaging and diagnostic services. You say that records show no authorization was 
obtained for this service. You have enclosed records and would like reconsideration for the denied charges to 
be allowed. The Plan denied your request. The Plan says the enrollee's primary care physician did not refer for 
services. The Plan requires utilization of network providers when possible and available and requires 
authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or 
emergency situation, has been documented. Medicare says non-urgent services should be from network 
providers who are contracted 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 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 diagnostic mammography (77066), a diagnostic 
digital breast tomosynthesis (G0279) and an ultrasound, breast, unilateral (76642) provided on June 9, 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 pneumatic compression device (PCD) and appliance 
provided on August 18, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this item is 
not payable for use outside the home. 
 
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 pay for the pneumatic compression device (PCD) and appliance provided on August 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 29822 and 29825 billed for date of service 
July 7, 2021. 
 You asked the Plan to pay for procedure codes 29822 and 29825. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says payment for the codes at issue is included in the 
payment for procedure code 29821. 
 
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 codes 29822 and 29825 are column II codes to column I code 29821; 
however, 29822 and 29825 were billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 29822 and 29825. Our reviewer says that 
the procedure codes at issue do not meet criteria for payment. Our reviewer found that the available medical 
documentation does not support 29825 to be billed separately, as it is included within procedure 29821, which 
is more comprehensive, and these procedures were performed on the same laterality. Medical documentation 
does not support the use of modifier 59 to be billed to unbundle these procedures. Medical documentation does 
not support the use of procedure 29822 to be billed separately as the procedure description is included in the 
main procedure of 29821. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 29822 and 29825 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 29822 and 29825 billed for date of service July 7, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for WATS-3D testing (88112, 88305, 88312, 88361) provided on February 
18, 2022. 
 
You asked the Plan to pay for WATS-3D testing. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says that the services at issue are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for WATS-3D testing. Our reviewer says that 
the services at issue are considered medically reasonable and necessary in this case. Our physician reviewer 
found that studies demonstrate that WATS-3D has high clinical utility. By prompting physicians to change 
their clinical management in patients with negative forceps biopsy results, WATS-3D, used adjunctively to 
forceps biopsy, directly impacts patient management and improves patient outcomes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of WATS-3D testing have been met. Therefore, we decided that the Plan has to 
pay for WATS-3D testing (88112, 88305, 88312, 88361) provided on February 18, 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: 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 the enrollee needs care in an IRF in order to improve 
maximum function and regain ability. The Plan denied your request. The Plan says the enrollee does not meet 
the criteria for coverage of IRF care. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for confusion, lethargy and a foot laceration. The enrollee's medical problems are stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports 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. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the MyoPro Orthosis is not known to 
be effective, based on scientific evidence, professional standards and expert opinion, in improving health 
outcomes. The MyoPro is not the standard of care for this enrollee's condition or in widespread use for this 
enrollees condition based on scientific evidence. There is insufficient evidence in the literature that the 
MyoPro Orthosis will improve the long-term outcomes for the enrollee. There is insufficient evidence in the 
literature that this device will increase participation in bimanual activities. 
 
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 a MyoPro Motion G orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92941 and 92978 billed for date of service 
March 10, 2022. 
 You asked the Plan to pay for procedure codes 92941 and 92978. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 92941 is: Percutaneous transluminal revascularization of 
acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass 
graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy 
when performed, single vessel. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 92941. Our reviewer says that that procedure 
code 92941 does not meet criteria for payment. Our reviewer found that the available medical documentation 
does not support that any procedure was performed. The documentation documents that the visit at issue was a 
consultation only. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 92941 have not been met. Furthermore, we have confirmed that 
code 92978 is an add-on code and has not been billed with an appropriate, payable primary procedure code. 
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 codes 92941 and 92978 billed for date of service March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical nerve stimulator (K1018, K1019). 
 
You asked the Plan to pre-approve the electrical nerve stimulator. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare 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 the electrical nerve stimulator have 
been met. Only one page of medical documentation was provided. Insufficient clinical documentation was 
provided to support this request. This device is covered for intractable pain. No records were provided to show 
a diagnosis of intractable pain.  
 
 
  
Therefore, we decided that the Plan does not have to pre-approve an electrical nerve stimulator (K1018, 
K1019).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 enrollee has retinal 
neovascularization. She has not tried and failed the Plan's required drug, bevacizumab. The records do not 
support that the required drug would be contraindicated or less effective; therefore, Eylea 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 Eylea.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says it is not safe for the enrollee to leave the hospital at 
this time because they have not finished their weaning from the respirator. The Plan says that the enrollee is 
receiving the care needed in the hospital where they are now and there is no need to transfer to an LTACH at 
this time. 
 
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 she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary for the enrollee's 
treatment. The Plan denied your request. The Plan says the use of the requested drug for spindle cell sarcoma 
requires documented tumor mutational burden-high tumors, as determined by an FDA approved test. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 pre-approve Keytruda. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found Keytruda is not FDA-approved for the 
enrollee's diagnosis. The use of Keytruda is not supported by one of the major drug compendia or by clinical 
research that appears in a Medicare-approved medical journal, as the enrollee is said to have progressed on 
prior immunotherapy. The documentation does not support that the requested drug is safe and effective and 
otherwise reasonable and necessary for this enrollee. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service May 26, 
2022. 
 
You asked the Plan to pay for procedure code 99233. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99233 is bundled into payment for code 36124. 
 
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 99233 
is a column II code to column I code 36124. 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 99233 billed for date of service May 26, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the provider is 
out-of-network, and it was determined these services can be received in-network. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve magnetic resonance imaging (MRI). 
Our physician reviewer found both requested MRIs are 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 magnetic resonance imaging (MRI) have been met. Therefore, we decided that 
the Plan has to pre-approve magnetic resonance imaging (MRI).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 enrollee has chronic hypercapnic 
respiratory failure from chronic obstructive pulmonary disease (COPD). The records indicate she was 
successfully treated with bi-level positive airway pressure (BiPAP) therapy. The records do not contain 
sufficient, detailed documentation to justify the use of a portable ventilator. The services are not reasonable or 
medically necessary at this time.  
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 a portable ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nucala. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nucala.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.