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

 
We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally 
invasive (indirect visualization), with image guidance (27279). 
 
You asked the Plan to pre-approve the surgical procedure. You say that based on your current evaluation and 
exam findings, the enrollee is a candidate for a sacroiliac joint fusion under fluoroscopic guidance. The Plan 
denied your request. The Plan says this procedure is considered investigational and is therefore not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image 
guidance (27279).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion oncology consult to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve a second opinion oncology consult to be provided by the requested out-of-
network provider. The Plan denied your request. The Plan says the services are not emergent/urgent and are 
available within the member's insurance 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a second 
opinion oncology consult to be provided by the requested out-of-network provider.
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 requested LTACH care is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for LTACH 
care have not been met. 
 
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 that the enrollee is receiving acute-hospital care, and acute-care services have not 
been denied. The documentation does not support that the enrollee in this case requires services at the LTACH 
that are not available at the acute-care hospital where the enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you do not meet criteria for the requested item. 
 
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.  
 
The file shows that your condition can be improved by a cane. This means that Medicare rules for coverage of 
a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance service, basic life support, non-emergency 
transport (A0425, A0428) provided on January 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a non-emergency ambulance transport. You say that you do not agree with the 
denial of these charges. The Plan denied your request. The Plan says prior authorization was not obtained by 
the provider or facility. The provider should have verified your eligibility, health benefits and obtained 
authorization prior to your service. 
 
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 ambulance service, basic life support, non-
emergency transport (A0425, A0428) provided on January 28, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eye surgeries (15823, 67900) for the enrollee. 
 
You asked the Plan to pre-approve the procedures. You say that the hooding has affected the enrollee's 
confidence in mobility and driving. The Plan denied your request. The Plan says the submitted photographs do 
not show that either eye being considered for surgery has physical signs consistent with a functional deficit or 
abnormality. 
 
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 procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the available documentation does not support that the enrollee has overhanging skin or 
upper eyelid position that is sufficiently low to produce a visually-significant field restriction of approximately 
30 degrees or less from fixation. The photographic evidence does not demonstrate redundant eyelid tissue that 
clearly obscures the line of sight in corresponding gaze. 
 
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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve eye surgeries (15823, 67900) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0480) provided on April 14, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you do not agree with the denial of the charges and are 
requesting reconsideration of payment for this claim. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. The provider should have verified the enrollee's 
eligibility, health benefits and obtained authorization prior to the visit before providing services to the enrollee. 
 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 drug testing (G0480) provided on April 14, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a toilet seat. 
 
You asked the Plan to pre-approve a toilet seat. You say that you need this because you have a hard time 
getting to the bathroom. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for J. Johnson, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a neurostimulator (64555, C1778, 
L8680). 
 
You asked the Plan to pre-approve implantation of a neurostimulator. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules have 
not been met because the requested service is experimental/investigational. 
 
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 implantation of a neurostimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that peripheral nerve stimulation for back pain remains experimental. More 
research is needed to demonstrate the safety and effectiveness of the requested service. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a neurostimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve implantation of a neurostimulator (64555, C1778, L8680).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27096 billed for date of service August 23, 
2021.  You asked the Plan to pay for procedure code 27096. You say that CPT code 27096-50 was billed correctly, 
and payment should be issued. The Plan denied your request. The Plan says CPT 27096 has an MUE value of 1 
but 2 units were billed. 
 
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 27096 is 1. The MAI value for this code is 2. You billed 2 units of this 
code on the original claim, exceeding the MUE. The record indicates that one unit of procedure code 27096 
billed on the original claim was paid. Based on this information, we decided that Medicare rules for coverage 
of procedure code 27096 on this claim have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 27096 billed for date of service August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 23, 2021 billed 
with codes 81225, 81226, 81227, 81230, 81240, 81241, 81249, 81291, 81335, 81355, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
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 23, 2021 billed with codes 81225, 81226, 81227, 81230, 81240, 81241, 81249, 81291, 81335, 
81355, and 81408.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) billed for date 
of service March 23, 2022. 
 You asked the Plan to pay for hospital discharge management. You say that this claim was denied as a 
duplicate in error. The Plan denied your request. The Plan says another provider has already billed and been 
paid for hospital discharge services for this enrollee and date. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that only one hospital 
discharge day management service is payable per patient per hospital stay.  
 
We looked at the file and Medicare rules. The record shows that another provider billed for hospital discharge 
management for date of service March 23, 2022. The record shows this claim has been paid by the Plan. Only 
one hospital discharge day management service is payable per patient per hospital stay. Based on this 
information, we decided that Medicare rules for coverage of hospital discharge management have not been met. 
Therefore, we decided that the Plan does not have to pay for hospital discharge day management (99239) billed 
for date of service March 23, 2022.
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 requested IRF care is a medical necessity for 
you. The Plan denied your request. The Plan says medical-necessity rules for IRF care have not been met. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on January 4, 2022, 
through January 12, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 tests. You say that you would like to be reimbursed for 
these at-home COVID-19 tests. The Plan denied your request. The Plan says prior to January 15, 2022, at-home 
COVID-19 tests requires proof of physician order. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 tests is an OTC item. The Plan did not offer a benefit for at-home COVID-19 tests without a 
provider order at the time these tests were purchased.  Therefore, we decided that the Plan does not have to pay 
for the at-home COVID-19 tests purchased on January 4, 2022, through January 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided September 28, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you were given incorrect insurance information. 
The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the chest x-ray was not filed until May 19, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the chest x-ray (71045) provided September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OptiChamber Diamond Spacer. 
 
You asked the Plan to pay for the spacer bag. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the spacer bag have not been met. Specifically, the requested spacer bag is not a covered benefit 
under Medicare Part B. Therefore, we decided that the Plan does not have to pay for the OptiChamber 
Diamond Spacer.  
 
Benefits for the spacer bag 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter crutch substitute (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that you need this because you are going to have 
surgery. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that lower leg platform crutch substitutes such as 
knee scooters are not covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a knee scooter crutch substitute (E0118).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81185,81286, 81400, 81413, 81414, 
81442, 81479) billed for date of service June 10, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services were ordered by a physician and 
are supported in the medical record. The Plan denied your request. The Plan says there is insufficient 
documentation to support that this order was requested by the enrollee's treating physician. 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 Medicare 
criteria for a service are met. The rules also say that while a physician order for diagnostic tests does not 
necessarily need to be signed, the physician must clearly document intent for the test to be performed. Tests 
which are not clearly ordered by the physician who is treating the beneficiary are considered not reasonable and 
necessary. 
 
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 laboratory services have been met. 
Specifically, the signature on the order form is not legible, and the information in the progress note does not 
support the intent for this testing to be performed. Therefore, we decided that the Plan does not have to pay for 
laboratory services (81185,81286, 81400, 81413, 81414, 81442, 81479) billed for date of service June 10, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 2, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 27, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 April 27, 2022.