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

 
We decided that the Plan does not have to pay for the lab testing services provided on August 22, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the testing was not 
indicated. 
 
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 lab services. Our physician reviewer 
found that the current standard of care for the investigation of onychomycosis in a toenail is to perform a 
potassium hydroxide (KOH) and or fungal culture to the specimen. These lab tests are inexpensive, sensitive, 
and specific. It is unclear as to why this enrollees right hallux nail specimen required polymerase chain 
reaction (PCR) testing when other less expensive and efficacious lab tests (KOH and fungal culture) are 
available. Therefore, the requested PCR testing was not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab testing services provided on August 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision of chest wall tumor including rib(s) rendered on 
November 16, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 21601 (1 unit) remains not supported. 
 
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 21601 is "Excision of chest wall tumor including rib(s)." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records provided do not include sufficient documentation to validate that CPT 21601 was rendered in this case. The code cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for excision of chest wall tumor including rib(s) rendered on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for trimming of dystrophic nails (code G0127) provided on 
March 11, 2022. 
 
You asked the Plan to pay for trimming of dystrophic nails. You say that the services were medically 
necessary. The Plan denied your request. The Plan says trimming of dystrophic nails is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
 Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Therefore, we decided that the Plan does not have to pay for trimming of 
dystrophic nails (code G0127) provided on March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar epidural steroid injection (ESI) (64483 and 
64484). 
 
You asked the Plan to pre-approve the ESIs. You say that this is needed for you to be independently mobile. 
The Plan denied your request. The Plan says the enrollee has had five (5) ESIs in the same level within less 
than a year and improvement of pain did not last for at least three (3) months. 
 
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 ESIs. Our physician reviewer found 
you have had five ESI in the same level within less than a year and per medical records, the improvement of 
pain did not last for three months. This request does not meet Medicare guidelines LCD 39054, as ESIs are 
limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month period, and at least 
50 percent relief in pain or function was not achieved for three months after previous injection. 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 the ESIs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the lumbar epidural steroid injection (ESI) (64483 and 64484).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 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 72 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 additional routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 RFA to the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found SI joint RFA remains experimental in spine care. More research is needed to show 
safety and efficacy.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA to the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bioness L300 Go Plus (leg) and the H200 (hand) 
device (E0770). 
 
You asked the Plan to pre-approve a Bioness L300 Go Plus (leg) and the H200 (hand) device. You say that the 
item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of NMES to treat muscle atrophy is limited 
to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and 
peripheral nerves, and other non-neurological reasons for disuse atrophy. Coverage of NMES to treat muscle 
atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, 
spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. 
 
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 Bioness L300 Go Plus (leg) and the 
H200 (hand) device. Our reviewer says that you do not need this medical item. Our physician reviewer found 
the provided medical records document multiple sclerosis and do not document that the patient in this case has 
non-neurological reasons for disuse atrophy or a spinal cord injury. 
 
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 Bioness L300 Go Plus (leg) and the H200 (hand) device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Bioness L300 Go Plus (leg) and the H200 
(hand) device (E0770).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stent placement with atherectomy and angioplasty 
(37227). 
 
You asked the Plan to pre-approve the surgical procedure. You say that please see attached letter and clinicals 
for review. The Plan denied your request. The Plan says the enrollee does not meet all of the required criteria. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support the medical necessity of the procedure in 
question. For the procedure to be considered medically necessary there would need to be evidence of limb 
threat or of lifestyle limiting/disabling claudication.  Fairly recent angiography demonstrated an area of 70% stenosis in the proximal left superficial femoral artery (SFA). The enrollee has essentially normal resting ankle-
brachial index (ABIs) and palpable pedal pulses. There is no suggestion of limb threat. It is noted that the 
enrollee is doing well and is playing pickle ball. There is a report of claudication in the left leg but not clear to 
what degree. There is no documentation that the enrollee is having lifestyle limitation. What is documented is 
that the enrollee is able to walk far enough to confirm that there is no claudication in the right leg. As it is not 
clear the enrollee is having lifestyle limiting symptoms, unable to overturn the health Plan determination. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve stent placement with atherectomy and angioplasty (37227).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One 
 You asked the Plan to pre-approve Gel-One. You say that a steroid injection only provided temporary relief. 
The Plan denied your request. The Plan says the enrollee has not tried the preferred products. 
 
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 Gel-One. Our physician reviewer found 
that the enrollee has right knee osteoarthritis. The Plan requires a trial of Durolane, Supartz FX, Gelsyn 3, or 
Euflexxa before they will approve the requested drug. In this case, the enrollee tried and failed the required 
drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less 
effective and/or likely have adverse effects for the 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal (81479) testing provided on June 4, 2022. 
 
You asked the Plan to pay for Guardant Reveal. You say that this test was medically reasonable and necessary. 
The Plan denied your request. The Plan says this test has not met Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of Guardant Reveal have not been met. Therefore, we decided that the Plan does 
not have to pay for Guardant Reveal (81479) testing provided on June 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the enrollee does not 
meet the coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablations of the paravertebral facet 
joint nerves (64635 and 64636).  
You asked the Plan to pre-approve the radiofrequency ablations of the paravertebral facet joint nerves. You say 
that the service is medically necessary. The Plan denied your request. The Plan says the service is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if there is an extended period of time, two years or 
more, since the last RFA and/or there is a question as to the source of the recurrent pain then diagnostic 
procedures must be repeated. 
 
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 radiofrequency ablations of the 
paravertebral facet joint nerves. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found the records show that the enrollee has untreated radicular pain as indicated by spinal stenosis 
and pain radiating to the left foot. In addition, it has been more than two years since the enrollee's last 
procedure and diagnostic medial branch blocks have not been repeated. 
 
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 radiofrequency ablations of the paravertebral facet joint nerves have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the radiofrequency ablations of the 
paravertebral facet joint nerves (64635 and 64636).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to approve the acute inpatient hospital care beginning April 12, 2023. 
 
You asked the Plan to approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 approve acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient care are met in this case. Our 
physician reviewer found the enrollee presented to the hospital with a COVID-19 infection and rhabdomyolysis 
requiring intravenous (IV) fluids, potassium, and lovenox. The initial treatment in the emergency department 
led to improvement in mental status but he was required to stay in the hospital due to COVID-19 quarantine 
rules. The records support he was stable to not require a hospital stay that would have likely crossed two 
midnights and could have remained in observation status during the remaining quarantine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to approve the acute inpatient hospital care beginning April 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel (87481, 
87556, 87641, 87798) provided on November 4, 2022. 
 
You asked the Plan to pay for the urine PCR panel. You say that this claim should be covered. The Plan denied 
your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This was a 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 urine PCR panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) panel (87481, 87556, 87641, 87798) provided on November 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for electrical stimulation provided from November 3, 2022, to  
November 17, 2022. 
 
You asked the Plan to pay for electrical stimulation. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the use of electrostimulation alone for neuropathies or peripheral 
neuropathies caused by underlying systemic diseases, is insufficient to warrant coverage. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not responded to our request for clarification. 
Therefore, we decided that the Plan has to pay for electrical stimulation provided from November 3, 2022, to 
November 17, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953) and biologic 
materials to aid in tissue regeneration (D4265). 
 
You asked the Plan to pre-approve the dental services. You say that you were told all items should be covered. 
You say you cannot have implants without a bone graft. The Plan denied your request. The Plan says these 
services are not covered under your dental benefit. 
 
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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft (D7953) and biologic materials to aid in tissue regeneration (D4265).