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

 
We decided that the Plan does not have to pay for the genetic testing provided on May 31, 2022, billed with 
codes 0031U, 0032U, 81225, 81227, 81230, 81231, 81291, 81328, 81355, 81226, 81240, 81241, 81401 and 
81479. 
 You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and were 
reported appropriately. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 31, 2022, billed with codes 0031U, 0032U, 81225, 81227, 81230, 81231, 81291, 81328, 81355, 81226, 
81240, 81241, 81401 and 81479.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 13, 2022, to 
June 11, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 13, 2022, to June 
11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says the seat elevator does not serve medical purpose and is statutorily non-covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the item have not been met. The rules say that a power seat 
elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily 
medical in nature. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation 
system (E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says more research is needed to show safety and efficacy of the procedure. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee was being treated for vertebrogenic low back pain and spondylosis without 
myelopathy or radiculopathy of the lumbar region. She presented with low back pain radiating into the hips and 
legs bilaterally. The exam reveals no lumbar findings. In this case, there were/are multiple plausible pathologic 
sources of significant pain generation. The back pain and lack of lumbar exam were/are all non-specific to any 
pathologic entities. Additionally, detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures including physical therapy. Overall, 
documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Intracept intraosseous basivertebral nerve ablation at L4 and L5 vertebral bodies, in this case, is 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, powered and 
programmable flexion/extension assist control (L5859) and a user-adjustable heel height feature (L5990). 
 
 You asked the Plan to pre-approve additions to lower extremity prosthesis. You say that the requested 
prosthetics are medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare 
requirements for the requested endoskeletal knee-shin system, powered and programmable flexion/extension 
assist control, and user adjustable heel height are not 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 additions to lower extremity prosthesis. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found The LCD states that the L5859 is covered if the patient "Has a 
documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that 
impairs K-3 level function with the use of a microprocessor-controlled knee alone." Provided medical records 
do not document the patient has any of these conditions. The LCD also states, "A user-adjustable heel height 
feature (L5990) will be denied as not 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 additions to lower extremity prosthesis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, powered and 
programmable flexion/extension assist control (L5859) and a user-adjustable heel height feature (L5990).
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 admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can safely be provided at the current facility until more appropriate for a 
lower level of care. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Transfer to the LTACH is not medically necessary at this time as it would 
not be clinically advantageous. Completion of treatment at the current facility is 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair, group 3 standard, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861) and 
the other requested items/accessories (E1007, E1028, E2613, E2377, E2313, E2311, K0040, E1012, E0955, 
E0956, K0040, E2359 and E2624). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the enrollee does not have medical need for multiple power options included with 
K0861 group 3 power wheelchair. E2311 Electronic connection, E2377 Expandable Controller and E2313 
Expandable Controller Harness cannot be covered as it is not medically necessary to control the three requested 
power options through the joystick (drive interface). The Plan states the enrollee meets criteria for a Group 3 
power wheelchair with no power options. 
 
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.  
 
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 DME. Our physician reviewer 
found the provided records do not support that the enrollee is high risk for skin breakdown. The enrollee has 
been wheelchair-bound for four years with no history of pressure ulcer(s) or skin flap surgery. Records do not 
document the enrollee performs bladder self-catheterization or that the enrollee has increased muscle tone or 
spasticity. Provided records do not document the enrollee has a musculoskeletal condition or the presence of a 
cast or brace which prevents 90-degree flexion at the knee, or the enrollee has significant edema of the lower 
extremities that requires an elevating legrest. Therefore, the enrollee does not meet LCD: Power Mobility 
Devices (L33789) criteria for multiple power options, power tilt/recline and elevating legrests. As the 
wheelchair base does not meet criteria for coverage, none of the accessories are covered. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to 
and including 300 pounds (CPT code K0861) and the other requested items/accessories (E1007, E1028, E2613, 
E2377, E2313, E2311, K0040, E1012, E0955, E0956, K0040, E2359 and E2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G Orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro 2 Motion G Orthotic device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says the device does not meet the requirements for approval. 
 
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 a MyoPro 2 Motion G Orthotic device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based on the medical records provided, there is no documentation that 
the MyoPro 2 Motion G Orthotic device at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the enrollee. Current clinical guidelines designate robotic therapy to be of 
"uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven 
benefit in the home environment. In addition, provided records report left upper extremity spasticity which may 
be a contraindication to use of the device. 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 MyoPro 2 Motion G Orthotic device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a MyoPro 2 Motion G Orthotic device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet injection lumbosacral level 1. 
 
You asked the Plan to pre-approve a facet injection lumbosacral level 1. You say that a facet injection 
lumbosacral level 1 is medically necessary. The Plan denied your request. The Plan says a facet injection 
lumbosacral level 1 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 facet injection lumbosacral level 1. 
Our reviewer says that the requested facet injection lumbosacral level 1 is not medically necessary in this case. 
Our physician reviewer found that in this case, there is no documentation of any trial of conservative therapy. 
According to the coverage criteria, facet injections are indicated when pain is present for minimum of 3 months 
with documented failure to respond to non-invasive conservative management (as tolerated). The review has determined that the requested facet joint injection does not meet the Medicare LCD 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 facet injection lumbosacral level 1 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a facet injection lumbosacral level 1.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services (70450 and 70551) provided on January 
27, 2022. 
 
You asked the Plan to pay for the imaging services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says required documentation for payment was 
not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the imaging services have been met. 
The Plan sent several requests for medical records that were not returned. Therefore, we decided that the Plan 
does not have to pay for the imaging services (70450 and 70551) provided on January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says your needs could be provided by a BiPAP device. 
 
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 a home ventilator. Our physician 
reviewer found that you were hospitalized with a COPD exacerbation recently. There are diagnoses of 
obstructive sleep apnea (OSA) and severe obesity. Your arterial blood gas (ABG) in hospital showed results, 
which may represent compensatory carbon dioxide (CO2) retention from the metabolic alkalosis. There is no 
documentation of chronic CO2 retention on ABG done while stable. There are no pulmonary function tests to 
confirm COPD and assess severity.   There is no diagnosis of thoracic restrictive disease or neuromuscular disease. If you do have severe COPD 
with chronic CO2 retention, you may benefit from BiPAP during sleep. However, Medicare does not cover a 
home ventilator when used as BiPAP. Therefore, the request is not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80307 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the CPT code is 
redundant to 80305. 
 
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 file shows that presumptive testing, 80307, was billed. We looked at the file and the rules. We find that 
code 80305 was previously billed for this date of service. Only one code from code range 80305-80307 may be 
reported per date of service. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
80307 billed for date of service May 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 30, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service July 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 10, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was medically necessary. 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 May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ImpediMed L-Dex testing (93702). 
 
You asked the Plan to pre-approve ImpediMed L-Dex testing. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
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 ImpediMed L-Dex testing. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that bioimpedance spectroscopy is considered experimental/investigational. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ImpediMed L-Dex testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve ImpediMed L-Dex testing (93702).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 10, 
2022, to February 8, 2022. 
 You asked the Plan to pay for SNF care. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the criteria for admission to SNF have not been met. 
 
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 pay for 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  
 
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 pay for skilled nursing facility (SNF) care provided from January 10, 2022, to February 8, 2022.