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

 
We decided that the Plan does not have to pre-approve a third additional level of facet joint injection services. 
 
You asked the Plan to pre-approve a third additional level of facet joint injection services. You say that this 
procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the standard of 
care is to have no more than 1 or 2 levels of injection services. 
 
The Plan follows Medicare rules. Medicare rules say that the need for a three or four-level procedure bilaterally 
may be considered under unique circumstances and with sufficient documentation of medical necessity on 
appeal 
 
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 a third additional level of facet joint 
injection services. Our reviewer says that the requested third level of injections is not medically reasonable and 
necessary. Our physician reviewer found the enrollee is a 74-year-old with tenderness over bilateral L3-4, L4-5, and L5-
S1, and positive facet loading tests. He failed conservative treatments with home exercise program and 
medication. In this case, there is no unique circumstances that would allow a third additional level of facet joint 
injection services. Therefore, the requested third level will not be covered per Medicare coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a third additional level of facet joint injection services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a third additional level of facet joint injection 
services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional trips. 
 
You asked the Plan to pre-approve additional trips. You say that you are requesting more trips because it is 
expensive for you to pay for transportation. The Plan denied your request. The Plan says you have exhausted 
the benefit coverage limit of one-way trips. The Plan also says that extra trips cannot be approved. 
 
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 up to 24 one-way 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 10 additional trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement that the codes billed are 
included in the dialysis rate. The Plan denied your request. The Plan says the services are the responsibility of 
the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 lab services provided on January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reduction mammaplasty. 
 
You asked the Plan to pre-approve a reduction mammaplasty. The Plan denied your request. The Plan says a 
reduction mammaplasty does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  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 a reduction mammaplasty. Our 
reviewer says that a reduction mammaplasty is not medically necessary. Our physician reviewer found the 
record indicates that the enrollee has macromastia. The provided record is insufficient to establish that the 
coverage criteria are satisfied. The elements of the coverage rules are not satisfied. The requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a reduction mammaplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a reduction mammaplasty.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that the requested drug is a medical necessity for you. The 
Plan denied your request. The Plan says that rules for coverage have not been met because the requested drug 
has been prescribed for an off-label and not medically supported use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that the 
requested drug is medically reasonable and necessary in this case. Our physician reviewer found that the FDA 
has stated that the requested drug is an extended-release synthetic corticosteroid indicated as an intra-articular 
injection for the management of osteoarthritis pain of the knee. The FDA updated the drug label in 2020 to 
remove the limitation that the drug is not intended for repeat use and modified the label to state that the 
efficacy and safety of repeat administration of Zilretta have not been demonstrated. 
 
In this case, the record indicates that you have a diagnosis of osteoarthritis-induced knee pain. The record 
indicates that you have had favorable results using the requested medication previously. The requested drug is 
being used for its current FDA-labeled indication. The FDA has not restricted the drug's use to a single 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 Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
treatment with Zilretta.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMDx test provided on January 7, 2021. 
 
You asked the Plan to pay for the SelectMDx test. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says Medicare criteria for coverage have not 
been satisfied for the genetic testing services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory tests must be approved under the 
DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. In this case, the ordered SelectMDx test is not currently approved for 
coverage under the DEXTM Diagnostics Exchange. Based on this information, we decided that Medicare rules 
for coverage of the SelectMDx test have not been met.  
  
 
Therefore, we decided that the Plan does not have to pay for the SelectMDx test provided on January 7, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the gene panel testing provided on October 5, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says that one code 
must be submitted for the panel. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The file shows that the gene panel at issue was billed with CPT code 81479. The case file does not include 
additional claims or claim information to show that the testing at issue was billed with multiple codes. The Plan 
has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request.  Therefore, we decided that the Plan has to pay for the gene panel testing provided on 
October 5, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional routine transportation trips. 
 
You asked the Plan to pre-approve 8 additional trips. You say that the enrollee needs to receive treatment once 
a week for 3 weeks along with other doctor appointments. You say that you rely on transportation for their 
medically needed travels. You also say that additional trips are needed. The Plan denied your request. The Plan 
says additional trips beyond the allowed 24 one-way trips per calendar year are not covered. 
 
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 24 one-way 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 8 additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of excess skin on your arms (brachioplasty). 
 
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 records show that you have 
excessive skin on your arms. There is no documentation of functional limitations or skin rash (intertrigo) that 
hasn't responded to conservative treatment. The records do not support that the brachioplasty is 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 removal of excess skin on your arms (brachioplasty).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 17, 2022. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are 
included in the dialysis rate. The Plan denied your request. The Plan says the labs are the responsibility of the 
dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 lab services provided on January 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertiflex procedure to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve vertiflex procedure. You say that the services are medically necessary. The 
Plan denied your request. The Plan says it has determined the service requested can be safely rendered in-
network. 
 
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 vertiflex procedure at issue in this appeal. We found no exception that would 
require the Plan to pre-approve the vertiflex procedure. Therefore, we decided that the Plan does not have to 
pre-approve vertiflex procedure to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left total knee replacement to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve left total knee replacement. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the left total knee replacement 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 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 left total knee replacement at issue in this appeal. We found no exception that 
would require the Plan to pre-approve the left total knee replacement. Therefore, we decided that the Plan does 
not have to pre-approve left total knee replacement to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cholecystectomy with exploration of the common bile duct 
(47610) provided November 9, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that the enrollee had multiple exams on this date 
of service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 24, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay for cholecystectomy with exploration of the common 
bile duct (47610) provided November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service rendered on February 1, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. 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 pay for the special 
anesthesia service rendered on February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 29, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. The next generation sequence testing (NGS) testing panel 
performed included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is 
statutorily excluded service. In addition to single gene testing, panels that include the FANCC gene are 
statutorily excluded service. Based on this information, we decided that Medicare rules for coverage of the 
laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne CDx (F1CDx) test (0037U) provided January 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 19, 2022 billed with 
codes 81455, 81301, 81194 and 81479. 
 
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 
January 19, 2022 billed with codes 81455, 81301, 81194 and 81479.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is an experimental treatment. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
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 would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for pleural effusion. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (81455) 
provided January 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the test was ordered by the treating 
physician because the test results were needed to help determine the course of treatment for this enrollee. The 
Plan denied your request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. CPT code 81455 is a Group 3 code and is unlikely to impact 
therapeutic decision-making in the clinical management of the patient and will be denied automatically as not 
medically necessary. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for targeted genomic 
sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when 
performed, 51 or greater genes (81455) provided January 6, 2022.