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

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. The Plan denied your request. The Plan says the 
genicular nerve block 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 the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary.  Our physician reviewer found that the enrollee 
has chronic right knee pain due to osteoarthritis of the knee and have been treated with medication and 
intraarticular steroid injections. The genicular nerve blocks and genicular nerve ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the speech therapy visits (92524) provided May 3, 2023, to 
May 31, 2023. 
 
You asked the Plan to pay for the speech therapy visits. You say that please review this claim and reconsider. 
The Plan denied your request. The Plan says there is no documentation provided to support the necessity of 
speech therapy for the enrollee. 
 
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 speech therapy visits have been 
met. medical records were needed from the provider. The records show that the Plan made multiple attempts to 
obtain the records without success. Therefore, we decided that the Plan does not have to pay for the speech 
therapy visits (92524) provided May 3, 2023, to May 31, 2023.
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 would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says admission to an LTACH is not medically 
necessary.  
 
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 that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 4, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on July 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile x-ray services billed with codes 74230, 72040, 
70100, 70310, 71045, and 74240 for January 18, 2023. 
 
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 billed with the incorrect place of service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for an 
office; however, the file shows that the services were performed in a mobile unit. Therefore, we decided that the Plan does not have to pay for the mobile x-ray services billed with codes 74230, 72040, 70100, 70310, 
71045, and 74240 for January 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo carotid sinus baroreflex device (C1825, 
0266T).  
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary for the enrollee's 
condition. You also say that the enrollee has failed guideline-directed medical therapy including beta blocker, 
diuretic, and Aldosterone inhibitor.  The Plan denied your request. The Plan says the device 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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable and necessary in this enrollee's clinical 
management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Barostim Neo carotid sinus baroreflex device (C1825, 0266T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the portable oxygen equipment (E1399) purchased 
September 21, 2022. 
 
You asked the Plan to reimburse you for the oxygen equipment. You say that you decided to do some traveling 
and found out you could not take oxygen tanks on an airplane. You had no other choice but to buy an Inogen 
portable. The Plan denied your request. The Plan says the equipment was purchased from a provider who is not 
certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen 
equipment (E1399) purchased September 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve self-administered drug code A9270 provided from 
March 15, 2023, to March 16, 2023. 
 
You asked the Plan to pre-approve the medication. You say that if you were told this would not be covered you 
would not have done it. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve self-administered drug code 
A9270 provided from March 15, 2023, to March 16, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 for date of 
service February 14, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, 96521, and J1817. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 96365, 96366, 96521, and J1817 are not supported in the medical record. Specifically, 
the documentation shows that Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, 
by any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea nitrogen 
(UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration was performed. There are 
more appropriate codes to be billed for the services rendered. This means codes 96365, 96366, and 96521 are not supported. 
 
The documentation shows that Nova R was administered via intravenous treatment. There is a more 
appropriate code to be billed for this service rendered; therefore, code J1817 is not supported. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 96365, 96366, 96521, and J1817 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, 
96521, and J1817 for date of service February 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records support the need for the IRF 
admission. The Plan denied your request. The Plan says based on Medicare guidelines and the information we 
have about the enrollee's condition they do not meet all the requirements for IRF admission. 
 
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 the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitation services and regular 
physician evaluation. The enrollee's needs can be met 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (scooter) (K0812). 
 
You asked the Plan to pre-approve a scooter. You say that you feel you should be approved as you can barely 
walk because you have rheumatoid arthritis. You also say that your bones are brittle, and an electric scooter 
would allow you to be more mobile. The Plan denied your request. The Plan says this request is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 scooter. Our reviewer says that you 
do not meet the criteria for coverage. Our physician reviewer found you have rheumatoid arthritis but are able 
to walk without a walker. Our reviewer also found that you do not require a scooter to perform MRADLs. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power operated vehicle (scooter) (K0812).
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 November 21, 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. In addition, codes 94761 and 99072 are 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. 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 November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that you are disabled 
and are unable to move around or get around inside or outside of your house. You also say that you are getting 
worse. The Plan denied your request. The Plan says there is no documentation indicating that you have had the 
required evaluations and meet the requirements, or that the power operated vehicle is for use in the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 1 standard power operated 
vehicle. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found you 
have rheumatoid arthritis and peripheral neuropathy, and are able to walk with a cane. Our reviewer also found 
that you do not require a power wheelchair to complete MRADLs. 
 
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 1 standard power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve romosozumab-aqqg (J3111). 
 You asked the Plan to pre-approve romosozumab. You say that romosozumab is indicated for this enrollee due 
to their severe osteoporosis, history of vertebral fracture, and high risk for future fracture which will be 
suboptimally treated with bisphosphonate. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for coverage. 
 
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 romosozumab. Our reviewer says that 
the enrollee does not meet the coverage criteria for romosozumab. Our physician reviewer found the provided 
records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record 
does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's 
preferred step one alternative. Our reviewer found that the elements of the coverage criteria are not satisfied. 
Our physician reviewer also found that 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 romosozumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve romosozumab-aqqg (J3111).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits (99204 and 99214) to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says your records received do not indicate that you have an 
emergent or urgent medical condition or are in need of specialized service(s) that are not available in the 
network. The Plan states that you have an HMO (Health Maintenance Organization) plan and there are in-
network provider(s) within a reasonable distance from your location that can provide this service or item. 
 
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 
the office visits (99204 and 99214) to be provided by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93005, 93306, 71406, 96365, 96366 and 96375 for 
date of service February 14, 2023. 
 
You asked the Plan to pay for codes 93005, 93306, 71406, 96365, 96366 and 96375. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be billed correctly. 
 
 We looked at the file and Medicare rules. Review of the file shows that a type A emergency dept level 5 visit 
was billed as identified by CPT code 99285 billed with rev code 450, along with 15 hours of observation 
services identified by CPT code G0378 billed with rev code 762. Therefore, a comprehensive APC of 8011 was 
assigned and a comprehensive payment was made for all services on the claim and according to the criteria for 
APC 8011, codes 71046, 93005, 93041, 93306, 94761, 96374 and 96375 are not separately payable. 
Based on this information, we decided that Medicare rules for coverage of codes 93005, 93306, 71406, 96365, 
96366 and 96375 have not been met. Therefore, we decided that the Plan does not have to pay for codes 93005, 
93306, 71406, 96365, 96366 and 96375 for date of service February 14, 2023.