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

 
We decided that the Plan does not have to pre-approve genicular nerve block injection. 
 
You asked the Plan to pre-approve genicular nerve block injection. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says there is not enough medical 
evidence that shows the procedure is helpful and safe for knee pain. 
 
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 genicular nerve block injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular nerve block is experimental for 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 genicular nerve block injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve block injection.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service May 3, 
2023.  
 
You asked the Plan to pay for procedure code A0425. You say that this service was medically necessary. 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 when an MUE has an MAI of 1, units in excess of the 
MUE are only payable when reported on a separate claim line with appropriate use of a modifier.  In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 309 units of 
this code on a single line, exceeding the MUE. The units in excess of the MUE were not reported on a separate 
claim line with an appropriate modifier as required. Based on this information, we decided that Medicare rules 
for coverage of procedure code A0425 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A0425 billed for date of service May 3, 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 LTACH care is reasonable and 
necessary. The Plan denied your request. The Plan says LTACH care is not reasonable and 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 the patient was admitted for atrial fibrillation with rapid ventricular response and 
congestive heart failure exacerbation and treated with intravenous antibiotics for aspiration pneumonia. She has 
also required two thoracenteses. The patient has not yet finished their acute hospitalization care and they do not 
qualify for an admission to a LTACH 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 procedure code 83789 billed for date of service June 22, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the drug testing is needed to monitor possible 
opioid abuse. The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 83789 billed for date of service June 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tramadol. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the Plan's denial. 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 Tramadol.  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0673, E0675) 
provided on May 10, 2023. 
 
You asked the Plan to pay for the pneumatic compression devices. You say that this device was provided for 
use during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The items at issue in this appeal were for use outside of the home. Although these items may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home.  
  Therefore, we decided that the Plan does not have to pay for the pneumatic compression devices (E0673, 
E0675) provided on May 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on April 6, 2023. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this 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 pay for the drug testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation listed tizanidine, gabapentin, oxycodone/acetaminophen, and nicotine gum as currently prescribed medications. However, the provided recent documentation did not clearly describe the 
enrollee as showing signs of drug abuse/misuse, nor were there results of a urine screening test showing 
unexpected results to justify definitive testing, particularly for more than 2 drug classes. Therefore, this request 
for definitive drug testing will be considered 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 the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing provided on April 6, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing (81479). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested service is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that the requested service is 
experimental/investigational. 
 
The Plan follows Medicare rules. The rules say that this test is reasonable and necessary when the criteria listed 
in the Medicare rules section of this letter 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 genetic testing. Our reviewer says that 
the requested services are medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee has metastatic cancer and has not been previously tested by the same test for the same genetic 
content and is seeking further treatment. The requested test has satisfactorily completed a TA by MolDX for 
the stated indications of the test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have been met. Therefore, we decided that the Plan has to pre-
approve genetic testing (81479).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 8, 2023, billed with 
codes 81209, 81218, 81334 and 81272. 
 
You asked the Plan to pay for the genetic testing billed with codes 81209, 81218, 81334 and 81272. You say 
that you have billed the services at issue correctly. 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 
with codes 81209, 81218, 81334 and 81272 have not been met. Therefore, we decided that the Plan does not 
have to pay for the genetic testing provided on May 8, 2023, billed with codes 81209, 81218, 81334 and 81272.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 15, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 15, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
November 15, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of November 15, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond November 15, 
2023, as she was not a danger to herself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from November 15, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 15, 
2023, forward.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's continued care needs include wound care, 
nutrition, physical therapy, occupational therapy, and antimicrobial treatment are approved and being treated in 
the current hospital without needing to transfer to a LTACH. 
 
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. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Given there are offered alternatives, LTACH is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary. The Plan denied your request. 
The Plan says IRF care 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 the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical records support need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 71045 and 73130 for date of service May 
25, 2023. 
 
You asked the Plan to pay for procedure codes 71045 and 73130. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services 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 CPT code. 
 
We find that CPT codes 71045 and 73130 are not payable as billed. Specifically, code 73130 is assigned a Q1 
indicator and CPT code 71045 is assigned a Q3 indicator (In other circumstances, payment is made through a 
separate Ambulatory Payment Classifications (APC) payment or packaged into payment for other services.) 
CPT code 99291 25 was assigned final status indicator S since the APC assigned was 5041. Codes 71045 and 
73130 are not separately payable as billed. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 71045 and 73130 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 71045 and 73130 for date of service May 25, 2023.
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 you would like the decision to be 
reconsidered for the benefit of the patient's health. The Plan denied your request. The Plan says the request for 
a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode with auto-
expiratory positive airway pressure that could be delivered by BiPAP is not covered.  
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy 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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the 
patient has chronic respiratory failure from COPD. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. Our reviewer 
found that the patient could be treated with a BiPAP machine with AVAPS capability and failure of such a 
device has not been documented. Our physician reviewer also found that the Plan has indicated coverage for 
such a device is available upon request. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 3, 2023, to 
August 1, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was submitted 
timely. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. The admission date on the claim does not match the admission date on the NOA. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 3, 2023, to August 
1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee is experiencing hallucinations and 
memory loss and a PET scan could help determine the diagnosis. The Plan denied your request. The Plan says 
the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the enrollee is noted to have 
undergone a PET scan in 2010 consistent with AD. The record provided does not establish that the enrollee 
meets the diagnostic criteria of both AD and FTD. The elements of the coverage criteria are not satisfied. The 
requested service cannot be covered 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.