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

 
We decided that the Plan does not have to pay for the CxBladder genetic testing services (0012M) provided on 
April 20, 2022. 
 
You asked the Plan to pay for the CxBladder genetic testing services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this testing is not covered 
by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy in place for CPT 
codes 0012M and 0013M for CxBladder. Based on this information, we decided that Medicare rules for 
coverage of the CxBladder genetic testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the CxBladder genetic testing services (0012M) provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture. 
 
You asked the Plan to pre-approve acupuncture. You say that you disagree with the denial. You have chronic 
pain in both hands that includes burning in your left foot. The Plan denied your request. The Plan says you are 
requesting acupuncture for hand pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 We looked at the file and Medicare rules. The records show that you are requesting acupuncture for pain in 
your hands. The EOC confirms that acupuncture is only covered for chronic low back pain. Based on this 
information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, 
acupuncture for the hands is not a covered benefit. Therefore, we decided that the Plan does not have to pre-
approve acupuncture.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee replacement procedure. 
 
You asked the Plan to pre-approve the requested services. You say that you are in pain. The Plan denied your 
request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that major joint replacement is only covered under certain 
medical 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 the requested services. Our physician 
reviewer found that you are being treated for primary osteoarthritis of the right knee. However, detailed 
documentation is not evident regarding any recent examinations that provide subjective and objective findings 
for the right knee. Moreover, there are no diagnostic imaging studies provided for review to corroborate right 
knee osteoarthritis. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the records do 
not show that the surgery is indicated for your condition. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a knee replacement procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has been stable in her 
weight since 2018. The Plan denied your request. The Plan says the enrollee's weight has not been stable for 6 
months. 
 
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 requested services. Our physician 
reviewer found that the enrollee had significant weight loss after bariatric surgery and has a pannus. The record 
indicates that the enrollee has yeast infections under the pannus, which is responsive to Diflucan. The record 
does not indicate a stable weight as the enrollee has had a 22-pound weight gain over the past six months. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. The elements of the coverage criteria are not satisfied. Therefore, the requested service is 
not 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a panniculectomy.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on December 17, 
2021. 
 
You asked the Plan to pay for F1CDx testing. You say that you would like this claim reprocessed and approved 
for payment as the testing performed was medically necessary. The Plan denied your request. The Plan says 
that this testing is a statutorily excluded service, and the claim was billed with an inconsistent date of service. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to a Food and Drug Administration 
(FDA)-approved test, as these are covered via the NCD cited in the Medicare rules section. A Local Coverage 
Determination (LCD) cannot limit coverage allowed by an NCD, per the Medicare hierarchy of authority. As 
such, we disregarded the LCD cited by the Plan. 
 
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. Medicare rules say that Medicare nationally covers FDA-approved NGS testing, such as the F1CDx 
panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. The Plan has further denied this claim 
stating an invalid date of service. The case file does not show that the lab service does not meet any of the 
exceptions outlined in the Medicare ruling for date of service issues. 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 FoundationOne CDx (F1CDx) testing provided on 
December 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on June 21, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that you are appealing with supporting 
documents. The Plan denied your request. The Plan says the enrollee must receive care from a 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for ophthalmological services provided on June 21, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for services provided on 
November 29, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient. We find that CPT code 99204 is not supported. The records show that a new 
patient visit was provided to the enrollee by the same physician within the previous 3 years. 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 99204 billed for services provided on 
November 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service February 1, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 70544 is bundled into 
payment for code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service February 1, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement provided on June 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for debridement. You say that the treatment rendered was medically necessary, and 
you are appealing with supporting record. The Plan denied your request. The Plan says the enrollee must 
receive care from a 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for debridement provided on June 27, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 3, 2022, 
to March 25, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were billed for two additional 
days that you were not at the facility, and you believe you should not have to pay for services that were not 
rendered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 
copayment per day for days 1 to 20 and $188 copayment per day for days 21 to 100 of an in-network skilled 
nursing facility stay. 
 
 
  You have been asked to pay a $376 copayment for days 21 and 22 of a SNF stay ($188 per day x 2 days = 
$376). This item/service falls within the Skilled Nursing Facility (SNF) Care benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a SNF stay provided from March 3, 2022, to March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on May 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee must receive care from a 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for ophthalmological services provided on May 23, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for UroVysion cytopathology services (88120) provided on 
March 14, 2022. You asked the Plan to pay for cytopathology services. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says these services were 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 pay for cytopathology services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are multiple urine markers that have improved sensitivity over cytology but 
there is lack of validation of clinical utility. Some of the recently developed markers aim to change the 
paradigm of urothelial diagnosis and follow-up by replacing or reducing the need of invasive investigations. 
Further prospective validations are needed to confirm these findings. Therefore, the requested testing was 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 cytopathology services have not been met. Therefore, we decided that the Plan 
does not have to pay for UroVysion cytopathology services (88120) provided on March 14, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services provided by an out-of-network provider on February 28, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were 
not authorized and are available in-network. 
 
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 requested services are not covered when provided by an 
out-of-network provider. However, the enrollee in this case has a PPO plan. As such, the Plan's contract 
indicates that payment can be made to non-contract providers for covered services. The Plan has not provided 
documentation substantiating its denial. Therefore, we decided that the Plan has to pay for the services 
provided by an out-of-network provider on February 28, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this device is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested device is not medically 
reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the requested HFCWOD is not medically reasonable and necessary.  
Our physician reviewer found that this enrollee has severe COPD, but there is no diagnosis of cystic fibrosis, 
bronchiectasis, or neuromuscular disease. There is inadequate evidence that this treatment is effective in 
COPD, and Medicare does not cover it for that diagnosis. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested Intracept procedure is considered 
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 the Intracept 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 87-year-old male was being treated for vertebrogenic low back pain. He 
presented with persistent pain in the low back that does not radiate. 
 
 
 
 
 In this case, there were/are multiple plausible pathologic sources of significant pain generation. The non-
radiating midline back pain, the noted pain-aggravating factor (activity), pain-relieving factor (medication), 
along with intact neurologic exam were/are all non-specific to any pathologic entities. 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 L5 and S1, 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a cardiac contractility modulation 
(CCM) system in the form of the Optimizer Smart device. 
 
You asked the Plan to pre-approve the implantation of a CCM system. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the records do not show the enrollee has 
heart failure symptoms suggestive of New York Heart Association class III or is on maximally 
tolerated/optimal guideline directed medical therapy. 
 
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 implantation of a CCM system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that at issue is whether implantation of the CCM system in this patient is 
medically necessary for the treatment of congestive heart failure which has been deemed refractory to optimal 
medical therapy. An exhaustive review of the current medical literature pertaining to the CCM system confirms 
multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of 
CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. 
While the clinical studies led to Food and Drug Administration approval in 2019, CCM remains the subject of 
multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to 
quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume 
clinical outcomes and benefit.  
 
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 implantation of a CCM system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the implantation of a cardiac contractility modulation (CCM) system 
in the form of the Optimizer Smart device.