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

 
We decided that the Plan does not have to pay for the chiropractic services billed with code 98941 for 
December 21, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that, for Medicare purposes, a chiropractor must place an 
AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation.  
 
We looked at the file and Medicare rules. The file shows that the chiropractic claim was not billed with the 
required -AT modifier. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. The Plan states that they will process the claim if a corrected claim is received 
from the provider. Therefore, we decided that the Plan does not have to pay for the chiropractic services billed 
with code 98941 for December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) provided on 
October 19, 2022. 
 
You asked the Plan to pay for the hospital outpatient clinic visit (G0463). You say that the service should be 
covered. 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 hospital outpatient 
clinic visit (G0463) provided on October 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex superion. 
 
You asked the Plan to pre-approve Vertiflex superion. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are 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 Vertiflex superion. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has lumbar spinal stenosis with neurogenic claudication. The Vertilfex 
device is experimental. More research is needed. Therefore, the enrollee does not meet criteria for the requested 
services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex superion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vertiflex superion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Apligraf, per square centimeter (code Q4101). 
 
You asked the Plan to pre-approve Apligraf, per square centimeter. You say that the member has had a venous 
ulcer on their right leg for over four months without improvement. You say the member has been treated in the 
wound clinic and by home health for two months that began on January 24, 2023, with the most recent date of 
service of March 22, 2023. The Plan denied your request. The Plan says the requested Apligraf, per square 
centimeter 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 Apligraf, per square centimeter. Our 
reviewer says that the requested Apligraf, per square centimeter is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee is a 72-year-old with a traumatic right medial leg ulcer complicated by peripheral edema and venous insufficiency. On January 31, 2023, the wound 
measured 1.5 x 0.7 x 0.2 cm. The enrollee was seen again on February 27, 2023. The ulcerate was noted to be 
slightly smaller with much more granulation tissue. The ulcer at that time measured 1.0 x 0.5 x 0.3 cm. The 
enrollee was evaluated on March 22, 2023. It was noted that the ulcer had somewhat improved. It measured 0.7 
x 0.2 x 0.1 cm. The records do not show that the wound has failed standard treatment. The wound has been 
steadily decreasing in size and as of March 22, 2023, was almost completely healed. The review has 
determined that the requested Apligraf, per square centimeter at issue 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 Apligraf, per square centimeter have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Apligraf, per square centimeter (code Q4101).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you should be eligible for this benefit. The 
Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 72100, 99202, and G0283 billed for 
December 12, 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 the services are not covered when performed by a chiropractor. 
 
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. The file shows that the 
chiropractor billed codes 72100 (lumbar spine x-ray, 2 or 3 views), 99202 (office visit) and G0283 (electrical 
stimulation). These codes are not covered when performed by a chiropractor. Therefore, we decided that the 
Plan does not have to pay for procedure codes 72100, 99202, and G0283 billed for December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0239U) 
provided November 16, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that FoundationOne Liquid CDx is a medically 
necessary laboratory test for patients with advanced stage, solid tumor cancers who have decided to seek 
further treatment. The Plan denied your request. The Plan says enrollees must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing have been met. The 
records show that the Plan made multiple attempts to obtain needed medical records from the provider without 
success. 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. Therefore, we decided that the Plan does not have to pay for the targeted 
genomic sequence analysis panel (0239U) provided November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says this procedure is considered 
experimental/investigational and/or unproven. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic left knee pain. She has tried and failed conservative therapy. 
She had diagnostic left genicular nerves block with 100% pain relief for 3 days. This is considered an 
experimental/investigational procedure which is the subject of ongoing clinical trials. Therefore, the request is 
deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance, when performed (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(A4239x6, E2103). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you have diabetes, and you have a 
phobia of needles. The Plan denied your request. The Plan says you do not meet criteria for approval of the 
CGM and supplies. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies (A4239x6, E2103).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service July 15, 
2022.  
You asked the Plan to pay for procedure code 0003A. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 0003A have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 0003A billed for date of service July 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 94761 and 99072 billed for date of 
service December 19, 2022. 
 
You asked the Plan to pay for procedure codes 87631, 94761 and 99072. You say that these services are 
supported in the medical records. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. The rules also say that for molecular 
diagnostic tests, such as the test at issue, the MolDX program requires these tests to be reviewed to determine 
whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is 
assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 87631 
have not been met.  
 
In addition, we find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99072 is not separately payable. We have also confirmed that procedure code 94761 
has a status indicator of T on the Physician Fee Schedule and was billed with other payable services under the 
physician fee schedule for the same date by the same provider. This means that procedure code 94761 is not 
separately payable in this case. Based on this information, we decided that Medicare rules for coverage of 
codes 99072 and 94761 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87631, 94761 and 99072 billed for date of service December 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration stating the enrollee needs to transfer to the LTACH to continue treatment. You say the skilled 
nursing facility is unable to accept due to medication cost. The Plan denied your request. The Plan says the 
LTACH services requested do not meet the requirements for approval. 
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee brace (L1846) and associated parts (L2425). 
 
You asked the Plan to pre-approve a knee brace and associated parts. You say that the items are medically 
necessary. The Plan denied your request. The Plan says The request exceeds the patient's needs. 
 
The Plan follows Medicare rules. Medicare rules say that If a custom fabricated orthosis is provided but the 
medical record does not document why that item is medically necessary instead of a prefabricated orthosis, the 
custom fabricated orthosis will be denied as not 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 a knee brace and associated parts. Our 
reviewer says that the enrollee does not need these items. Our physician reviewer found the patient is 
ambulatory but the documentation does not reveal evidence of objective joint laxity or instability on a physical 
examination. There is no evidence of a recent injury. The patient's surgery was on February 7, 2023 and her 
symptoms were noted on the March 14, 2023 progress note to have worsened recently in the prior week or two. 
The documentation does not reveal that the patient has failed a prefabricated brace or extenuating physical 
characteristics of the knee that requires the use of a custom fabricated orthosis instead of a prefabricated 
orthosis. The request exceeds the patient's needs. 
 
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 knee brace and associated parts have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a knee brace (L1846) and associated parts (L2425).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 15, 2022, billed 
with codes 81120, 81121, 81173, 81194, 81201, 81210, 81235, 81236, 81242, 81272, 81275, 81279, 81292, 
81295, 81298, 81301, 81307, 81309, 81311, 81314, 81321, 81339, 81345, 81351, 81400, 81401, 81403, 81404, 
81405, 81406, 81407, and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 
November 15, 2022, billed with codes 81120, 81121, 81173, 81194, 81201, 81210, 81235, 81236, 81242, 
81272, 81275, 81279, 81292, 81295, 81298, 81301, 81307, 81309, 81311, 81314, 81321, 81339, 81345, 81351, 
81400, 81401, 81403, 81404, 81405, 81406, 81407, and 81408.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for NxGen MDx testing (81514) provided on December 5, 2022. 
 
You asked the Plan to pay for NxGen MDx testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of NxGen MDx testing 
have not been met. Therefore, we decided that the Plan does not have to pay for NxGen MDx testing (81514) 
provided on December 5, 2022.