Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve additional physical therapy visits. 
 
You asked the Plan pre-approve additional physical therapy visits. You say that you need physical therapy to 
work on a range of motion and strength of the leg so you will be able to use a prosthetic. The Plan denied your 
request. The Plan says your request is not medically necessary because your records do not show that you are 
under the care of a physician or other allowed practitioner who has developed and certified a plan of care. We 
are unable to approve this request. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 pre-approve additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found you have had prior therapy and the documentation 
does not reveal that you require the unique skills of a professional therapist to provide treatment safely and 
effectively. Our reviewer also found that the services can be safely and effectively performed only by a 
therapist, or by or under supervision of a therapist. The documentation also does not support that you require 
additional ongoing skilled therapy without evidence that you are under the care of a physician who establishes 
and signs a plan for ongoing home health care therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have pre-approve additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on March 2, 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 the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 27006: 
 
Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure) 
 
CPT 27134: 
 
Revision of total hip arthroplasty; both components, with or without autograft or allograft 
 
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 for 27006, during the procedure, he had extensive trochanteric bursitis and near bald trochanteric region with the posterior one half of the stroke 
completely bald. An L-shaped capsulotomy was performed and two tagging sutures were placed within the 
neck capsule. A synovectomy was performed. The capsule was released inferiorly. However, the 
documentation does not corroborate that a tenotomy, abductors and/or extensor(s) of hip, open (separate 
procedure) was performed. For 27134, during the procedure, there is clearly a revision of the femoral 
component demonstrated. However, acetabular component was assessed and deemed it well fixed. This was 
irrigated. Therefore, revision of total hip arthroplasty, both components, with or without autograft or allograft, 
is not supported. 
 
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 surgical services provided to the enrollee on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99358 and 99359 billed for date of service 
February 21, 2022. 
 
You asked the Plan to pay for procedure codes 99358 and 99359. You say that these services were medically 
necessary and reasonable. The Plan denied your request. The Plan says the payment for these services is 
bundled into the payment for code 99310. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
99358 and 99359 are both column II codes to column I code 99310. Both code pairs have a modifier indicator 
of 0. The column II codes are therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99358 and 
99359 billed for date of service February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
March 17, 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 0037U is targeted genomic sequence analysis, solid organ 
neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the claim did not contain a 
Dex-Z Code unique identifier required by Medicare. 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 March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 22, 2022, billed with 
codes 81404, 81405, 81406, 81407, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 
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 
March 22, 2022, billed with codes 81404, 81405, 81406, 81407, and 81408.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 2, 2021, billed with 
codes 81401, 81301, 81317, 81309. 
 You asked the Plan to pay for the genetic testing billed. You say that the requested Tempus Gene Panel test is 
medically necessary and a valuable tool when determining treatment for the enrollee. The Plan denied your 
request. The Plan says your request does not meet Medicare rules as the testing performed was not FDA 
approved. 
 
The Plan must follow Medicare rules. The rules say that NGS as a diagnostic laboratory test is reasonable and 
necessary and covered nationally, if all criteria are met. 
 
We looked at the file and Medicare rules. The requested testing was not FDA approved; therefore, the testing is 
not approved. 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 March 2, 2021, billed with codes 81401, 81301, 81317, 81309.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel provided on August 5, 2020. 
 
You asked the Plan to pay for the general health panel. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
provided on August 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 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 screening testing for travel is not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a respiratory panel, was requested solely for screening purposes for travel. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80050) provided July 24, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this code is 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 80050 is not supported in the medical record. Specifically, the code billed is not eligible 
for Medicare payment. 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 lab services (80050) 
provided July 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychosocial rehabilitation services. 
 
You asked the Plan to pre-approve  the psychiatric services. You say that your doctor recommended mental 
rehabilitation therapies for you to treat your depression. The Plan denied your request. The Plan says the 
enrollee does not meet medical necessity criteria for outpatient 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 psychiatric services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee suffered from depression. Based on review the records provided, the 
enrollee was a very active person. This enrollee is not appropriate for this type of therapy as symptoms are not 
in excess. Based on review the records provided this enrollee does not meet the criteria for Psychosocial 
Rehabilitation Services based on LCD L34616 and could be treated at a lesser restrictive environment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychiatric services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve psychosocial rehabilitation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) Shoulder-elbow-wrist-
hand orthosis (L3960) provided January 27, 2022. 
 You asked the Plan to pay for the orthoses. You say that you disagree with this assessment and are attaching 
the following records for consideration. The Plan denied your request. The Plan says services not documented 
in the medical records. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the referring provider signature was dated for 
January 26, 2022, however, the records show that the enrollee was not seen by the physician until February 8, 
2022. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) 
Shoulder-elbow-wrist-hand orthosis (L3960) provided January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64483 and 64494 billed for date of service 
February 2, 2022. You asked the Plan to pay for procedure codes 64483 and 64494. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
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 codes [enter CPT code] is 1. The MAI value for these codes is 2. You billed 2 
units of each code code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 64483 and 64494 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 64483 and 64494 billed for date of service February 2, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the mental health services provided on March 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this type of 
provider is not payable. 
 
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. The plan argues that the services were provided by a registered nurse, and that 
this type of provider is not eligible for payment. However, the documentation, shows that the provider is a 
nurse practitioner, which is an eligible provider type for the requested services. As such, the submitted 
documentation contradicts the Plan's argument, and the Plan's denial cannot be substantiated. Therefore, we 
decided that the Plan has to pay for the mental health services provided on March 21, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided on April 29, 2022, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 2, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue.  We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the services provided on May 2, 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 pneumatic compression device identified with code 
E0651. 
 You asked the Plan to pre-approve a pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that PCDs are only covered for certain indications. 
 
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 pneumatic compression device. Our 
reviewer says that the documentation does not support that Our physician reviewer found the provided medical 
records do not document lymphedema. Your diagnosis is chronic peripheral venous insufficiency. No venous 
stasis ulcers are documented, and the records do not document failure of clinical treatment over the course of a 
required four-week trial of compression, elevation and exercise. Therefore, you do not meet criteria for the 
requested 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 pneumatic compression device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compression device identified with code E0651.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Avonex pen. 
 
You asked the Plan to pre-approve an Avonex pen. You say that it is medically necessary for the enrollee to 
continue using Avonex weekly in management of their longtime diagnosis of multiple sclerosis. The Plan 
denied your request. The Plan says the requested drug is not of a type and/or used for a condition that is 
covered under the medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve an Avonex pen.  
 
Benefits for an Avonex pen 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supervised physical medicine and rehabilitation modalities 
provided on May 3, 2022. 
 
You asked the Plan to pay for supervised physical medicine and rehabilitation modalities. You say that the 
service were provided by a chiropractor and should be covered. The Plan denied your request. The Plan says 
that the Plan covers only manual manipulation of the spine to correct subluxation and other services performed 
by a chiropractor are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for supervised physical medicine and rehabilitation modalities (code 97014) 
provided on May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 4, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on March 4, 2022.