Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for an orthopedic surgeon. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services are available in the network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for an orthopedic surgeon.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you feel the enrollee will be able to benefit from the 
rehabilitation at the SNF. The Plan denied your request. The Plan says the enrollee does not meet the medical 
necessity criteria for services in a SNF.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs, custodial and intermittent, can be provided 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150 rendered on January 30, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 87150-XU (8 Units) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 87150 is "Culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed." 
 
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 although the service was reported 
with modifier XU (unusual non-overlapping service), the laboratory report does not include documentation to 
support the modifier reported. There is no evidence that CPT 87150 as a separate and distinct procedure. The 
procedure was denied correctly. 
 
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 procedure code 87150 rendered on January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99152 billed for date of service January 20, 2023. 
 
You asked the Plan to pay for code 99152. You say that medical records were provided to support payment. 
The Plan denied your request. The Plan says code 99152 is not supported by the medical record. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patients level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 
5 years or older. 
 
 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 code 99152. Our reviewer says that code 99152 is not 
supported by the medical record. Our reviewer found the documentation did not have any time requirements 
met or that this was supervised by another provider. Per coding guidelines, the requirements were not met, and 
the documentation cannot verify that sedation was used 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99152 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99152 billed for date of service January 20, 2023.
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 the enrollee requires a higher level of rehab services 
in an effort to optimize their mobility and strength. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for admission to an IRF.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
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 the enrollee does not meet criteria for approval of a ventilator. 
 
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 reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS 
and a back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a 
back-up rate. 
 
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 (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 110 miles for one-way trip of routine transportation. 
 You asked the Plan to pre-approve additional mileage. You say that you have been going to this pain clinic 
monthly. You also say that you need these rides to be covered for continuous management. The Plan denied 
your request. The Plan says the requested mileage exceeds the benefit of 50-miles per trip. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, no mileage over the 
benefit of 50-miles per trip are not covered. Therefore, we decided that the Plan does not have to pre-approve 
110 miles for one-way trip of routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee surgery procedures (29873, 29884). 
 
You asked the Plan to pre-approve knee surgery procedures. You say that the requested knee surgery is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested knee surgery is 
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 pre-approve knee surgery procedures. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that detailed documentation is not evident in the case record regarding diagnostic 
imaging corroborating pathology of the left knee that could potentially benefit from the requested procedure. 
Moreover, the most recent examination did not objectively corroborate that the left-knee range of motion is significantly decreased. There are limited large-scale, long-term references showing the safety and efficacy of 
the requested surgery in this clinical setting. No compelling rationale is presented nor extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee surgery procedures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve knee surgery procedures (29873, 29884).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99221) provided on September 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (99221) is included in the global 
surgery payment for the procedure (33533) provided on September 19, 2022. 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 the services (99221) provided on September 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transluminal dilation of aqueous outflow canal 
(66174). 
 
You asked the Plan to pre-approve a transluminal dilation of aqueous outflow canal. You say that the requested 
service is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 
service is 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 a transluminal dilation of aqueous 
outflow canal. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that there is insufficient evidence in the published clinical 
literature to determine the safety and efficacy of goniotomy (e.g., OMNI transluminal dilation) for all other glaucoma types except pediatric glaucoma. 
 
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 transluminal dilation of aqueous outflow canal have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a transluminal dilation of aqueous outflow canal 
(66174).
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 is stable and no longer needs 
to remain in a short term acute care hospital. You say all of the enrollee's needs can be met at a lower LTACH 
level of care that can closely monitor their respiratory status, nutrition, neurological status and signs of 
infection. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage renal disease (ESRD) related services monthly, 
for patients 20 years of age and older; with 4 or more face-to-face visits per month (90960) provided on 
September 1, 2022. 
 
You asked the Plan to pay for the physician service. You say that you have been seeing the enrollee since 2020. 
You say that the service was urgent. You say that you cannot stop care because you are non-participating with 
the enrollee's insurance. You also say that this should be paid. The Plan denied your request. The Plan says this 
claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed.  
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 19, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the physician service have not been met. 
Therefore, we decided that the Plan does not have to pay for the end-stage renal disease (ESRD) related 
services monthly, for patients 20 years of age and older; with 4 or more face-to-face visits per month (90960) 
provided on September 1, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the enrollee has taken Fosamax for years. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, injectable 
bisphosphonates. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed injectable bisphosphonates, including Pamidronate, Zoledronic Acid, 
Ibandronate. The reviewer also found that there is no documentation provided indicating that the Plan's 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 7, 2022, billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81241, 81306, 81328, 81335 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically 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 
August 7, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81241, 81306, 81328, 
81335 and 81355.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (0363U) provided on February 9, 2023. 
 
You asked the Plan to pay for the lab testing. You say that this test was medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that biomarker testing is covered when medically 
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 pay for the lab testing. Our reviewer says that the 
requested service was not medically necessary. Our physician reviewer found in this case CxBladder is being 
used for diagnosis and not for surveillance. It remains unclear whether these tests offer additional useful 
information for detection and management of non-muscle invasive bladder tumors. More research is needed to 
support this use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not 
have to pay for lab testing (0363U) provided on February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sacroiliac joint (SIJ) radiofrequency ablation (RFA) 
provided on January 5, 2023. 
 
You asked the Plan to pay for the RFA procedure. You say that it is felt that this treatment was medically 
necessary. The Plan denied your request. The Plan says Medicare does not consider RFA of the sacral nerves to 
be reasonable and necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that SIJ RFA procedures are not considered 
reasonable and necessary.  Therefore, we decided that the Plan does not have to pay for the sacroiliac joint 
(SIJ) radiofrequency ablation (RFA) provided on January 5, 2023.