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 April 10, 2023, billed with 
codes 81162, 81201, 81295, 81298, 81307 and 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. 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 
April 10, 2023, billed with codes 81162, 81201, 81295, 81298, 81307 and 81317.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service March 5, 
2023. 
 
You asked the Plan to pay for procedure code 99140. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99140 is considered bundled 
and 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 procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service March 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health physical therapy visits. 

You asked the Plan to pre-approve home health physical therapy services.. You say that the requested home 
health physical therapy visits are medically necessary because the enrollee has benefited from the physical 
therapy visits. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health physical therapy services. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
that the enrollee does not have documented, ongoing, home health physical therapy needs. There is no evidence 
of a new illness or injury. The enrollee appears to be at a plateau in function. Skilled services are not required 
to establish a maintenance program or to prevent deterioration of the enrollee's condition. The requested home 
health physical therapy services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health physical therapy services. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 4 home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option 
and accessories (E0955, E1002, E1028, E2310, E2361, E2603, E2620, K0856). 

 You asked the Plan to pre-approve a group 3 power wheelchair with single power option and accessories. You 
say that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
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 group 3 power wheelchair with single 
power option and accessories. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found provided records do not support that the enrollee is high risk for skin breakdown (enrollee 
ambulates up to 15 feet and is contact guard assist for transfers), has a history of pressure ulcer(s) or has had 
skin flap surgery. Records do not document the enrollee performs bladder self-catheterization or that the 
enrollee has increased muscle tone or spasticity to meet criteria for the power tilt and thus the single power 
option base. As the requested wheelchair base does not meet Medicare coverage criteria, the requested 
accessories are not 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 a group 3 power wheelchair with single power option and accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with 
single power option and accessories (E0955, E1002, E1028, E2310, E2361, E2603, E2620, K0856).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #6 and #7. 
 
You asked the Plan to pre-approve the dental services. You say that you currently have dentures and the bottom 
crowns need to be replaced. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because they are not medically necessary. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
  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 dental services. Our reviewer says 
that the crowns are not medically necessary. Our physician reviewer found that the clinical notes indicated a 
porcelain fracture on tooth #7 crown, which is splinted to tooth #6.  There is no indication of decay around 
either of the units in question. A crown unit is considered to have failed when it has recurrent decay around it 
such that the tooth will be damaged further by the decay process if the crown is not replaced. In this instance 
the issue is cosmetic in nature and does not compromise the function of the crown units. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2751) for tooth #6 and #7.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99214) provided on May 4, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that that Rural Health Clinics (RHC)'s and Federally 
Qualified Health Centers (FQHC)'s paid under the AIR are required to file a cost report annually in order to 
determine their payment rate. If a RHC or FQHC is in its initial reporting period, the MAC calculates an 
interim rate based on a percentage of the per-visit limit, which is then adjusted when the cost report is filed. 
 
We looked at the file and Medicare rules. A rate letter was not provided. The plan requested additional 
information and it was not submitted. Based on this information, we decided that Medicare rules for coverage 
of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services (99214) provided on May 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigational procedure for 
musculoskeletal procedures (20985). 
 
You asked the Plan to pre-approve the computer-assisted surgical navigational procedure. You say that this is 
necessary to remove dissimilar mental interfaces responsible for metallosis, relieve pain, stop progression of 
current symptoms, and improve quality of life. The Plan denied your request. The Plan says the clinical value 
and effectiveness of computer assisted surgical navigation in the setting of hip surgery have not been 
demonstrated in the peer-reviewed literature. 
 
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 computer-assisted surgical 
navigational procedure. Our reviewer says that the requested computer-assisted surgical navigational procedure 
is not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the noted pathology. Clinical benefits/ultimate outcomes of functional improvement and pain 
reduction with computer navigation have not been documented to exceed non-navigated hip arthroplasty. There 
is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested computer-assisted surgical navigational procedure 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 computer-assisted surgical navigational procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve computer-assisted surgical navigational 
procedure for musculoskeletal procedures (20985).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the requested Euflexxa is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Euflexxa. Our reviewer says that the 
requested Euflexxa is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of osteoarthritis of the knees. The record indicates that the enrollee last received the 
requested service in April 2023 but does not contain subsequent notes documenting the effect of these 
injections. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. 
The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic code L5999. 
 
You asked the Plan to pre-approve the requested item. You say that code L5999 will accommodate for extra 
stress the socket will endure.  The Plan denied your request. The Plan says the code should not be used for a 
feature of a socket. 
 
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 L5999 is not supported. The use of code L5999 is incorrect coding when used to bill for 
features or functions of a socket. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pre-approve prosthetic code L5999.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy/sclerotherapy of left 
anterior tributary vein.  You asked the Plan to pre-approve endovenous ablation therapy/sclerotherapy of left anterior tributary vein. 
You say that this therapy is intended to treat a serious medical condition. You say that failure to undergo this 
therapy would result in inadequate treatment and will have serious consequences to the patient. The Plan 
denied your request. The Plan says endovenous ablation therapy/sclerotherapy of left anterior tributary vein 
does not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that endovenous ablation therapy/sclerotherapy is covered 
when the criteria listed in the Medicare rules section of this decision are met. 
 
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 endovenous ablation 
therapy/sclerotherapy of left anterior tributary vein. Our reviewer says that the requested endovenous ablation 
therapy/sclerotherapy of left anterior tributary vein is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that for treatment of tributary veins to be considered medically necessary 
per coverage criteria the veins must be greater than 4 mm in diameter. This condition has not been 
met. Additionally, coverage criteria require that the patients symptoms be due to the varicose veins. In this 
case, the patient has a history low back pain, and has documentation of an inability to perform even basic life 
functions despite six vein procedures. This strongly suggests an alternative etiology for the patients 
symptoms.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy/sclerotherapy of left anterior tributary vein have 
not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation 
therapy/sclerotherapy of left anterior tributary vein.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to go to rehabilitation in the hospital and 
you need the authorization approved right away. The Plan denied your request. The Plan says the request is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical or occupational therapy, at an intensive rehabilitation 
therapy program. You continue to have a need for skilled therapy however, the documentation doesnt support 
that you meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least three visits weekly to regain or maintain your functional status. You 
can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 enrollee needs to be transferred to 
Long Term Acute Care Hospital to regain maximum/prior level of functioning and continue multi-disciplinary 
approach to care. The Plan denied your request. The Plan says the enrollee's records do not show that it is 
medically safe to go to an LTACH and may stay in the hospital to finish hospital treatments. 
 
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 is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the LTACH 
admission. 
 
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's medical condition appears to be stable. The enrollee does not appear to 
require additional inpatient days of care that would likely meet or exceed 25 days. The services the enrollee 
requires are available at the facility where they are currently receiving care.  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84436 and 84479 billed for date of service 
April 26, 2023.   

You asked the Plan to pay for procedure codes 84436 and 84479. You say that the lab service was medically 
necessary. The Plan denied your request. The Plan says payment for code 84436 and 84479 is bundled into 
payment for code 84439. 
 
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 84436 and 84479 are column two codes to column one code 84439 
with a modifier indicator of 0. The column two 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 84436 and 84479 billed for date of service April 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 19, 2023, to 
February 17, 2023. 
 You asked the Plan to pay for the home health services. You say that you believe the Plan should bypass the 
NOA timely filing rules because of COVID-19. The Plan denied your request. The Plan says the NOA was not 
received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 19, 2023. The NOA was not received by the Plan until March 20, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 19, 2023, to February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 03, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on May 03, 2023.