Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (procedure code G0482) 
rendered on November 2, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not 
used in clinical management exceeds the 
needs of the enrollee. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there were no unexpected findings or report of suspicious behavior to suggest other drugs might 
have been used/misused. Confirmation testing was not appropriate in this situation, particularly for 15-21 drug 
classes which was much more than would be needed for this enrollee who is only taking one regulated 
medication.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for definitive urine drug testing (procedure code G0482) rendered on November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ultra Voice speaking device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. 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 pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided documentation in this case recommends this device for communication with little 
further detail. The records do not contain all of the elements of the required evaluation. 
 
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 an Ultra Voice speaking device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72192 billed for date of service March 10, 
2023. 
 You asked the Plan to pay for procedure code 72192. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 72192 is bundled into payment for code 74160. 
 
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 code 72192 
is a column II code to column I code 74160. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 72192 billed for date of service March 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. 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 services. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found you do not have documented 
skilled nursing needs. You appear to require custodial/supervisory care.  As such, the requested, ongoing, home 
health skilled nursing 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by 
the out-of-network (OON) provider on January 3, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out-of-network 
provider, without prior authorization. 
  
 
 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-network 
(OON) provider on January 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy (15830, 15847). 
 
You asked the Plan to pre-approve a panniculectomy. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity coverage criteria are not met since the documentation does not 
demonstrate any concerns for chronic intertrigo or rash. 
 
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 panniculectomy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the panniculus causes chronic intertrigo that 
consistently recurs or remains refractory to appropriate medical therapy over a period of 3 months, or an 
inability to walk normally. 
 
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 panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy (15830, 15847).
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous. Completion of treatment at the current facility is 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 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 pre-approve hereditary breast and ovarian cancer gene testing 
(BRCA1 and BRCA2). 
 
You asked the Plan to pre-approve genetic cancer testing. You say that this test is medically necessary because 
the enrollee has family history of breast and ovarian cancers. The Plan denied your request. The Plan says this test is considered a screening which is not covered by Medicare because the enrollee has no personal history of 
cancer. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, genetic cancer testing, is being requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pre-approve hereditary breast and ovarian cancer gene testing (BRCA1 and BRCA2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis and an autograft for spine surgery 
 
You asked the Plan to pre-approve arthrodesis and an autograft for spine surgery. You say that the enrollee 
states that they have pain and would benefit from this procedure. The Plan denied your request. The Plan says 
the enrollee does not have daily pain that is severe or rated at least 7 out of 10 on a pain scale. 
 
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 arthrodesis and an autograft for spine 
surgery. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the exam reveals right ischiogluteal bursa tenderness and 
left sacroiliac/hip joint line tenderness. There is bilateral lumbar paraspinous tenderness. No facet 
loading/tenderness. 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, or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested decompression 
and fusion at L4-5 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 arthrodesis and an autograft for spine surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve arthrodesis and an autograft for spine surgery
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile x-ray services billed with codes 92611, 74230-26, 
74240-26, 92611, 74230-26, and 74240-26 for January 5, 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 not billed with the correct place of service 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 file shows that the claim was incorrectly billed with POS code 
11 for an office. The services were performed in a mobile unit in a skilled nursing facility. Therefore, we decided that the Plan does not have to pay for the mobile x-ray services billed with codes 92611, 74230-26, 
74240-26, 92611, 74230-26, and 74240-26 for January 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 
10, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G7 sensors.  
You asked the Plan to pre-approve the Dexcom G7 sensors. You say that your doctor suggested the Dexcom 7 
sensor and you have been using samples from his office. You also say that in three weeks, it's given you a 
running A1C where you can see what it's doing over that period.  The Plan denied your request. The Plan says 
after a review of your prescription claims, you are not using any insulin. In addition, your provider stated that 
you have not had any hypoglycemic (low blood sugar) episodes. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Dexcom G7 sensors. Our reviewer 
says that the Dexcom G7 sensors are not medically necessary. Our physician reviewer found the criteria for 
CGM require insulin use or level 2 or 3 low blood glucose sugar. This means blood glucose lower than 54 with 
symptoms, despite changes in medication or low blood glucose sugar requiring outside assistance. Although 
the CGM has seemed to help you improve control and seems like a good prescription for you, the criteria 
coverage is not met. We are also not told of any insulin 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 Dexcom G7 sensors have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Dexcom G7 sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S1015 billed for date of service August 19, 
2022. 
 
You asked the Plan to pay for procedure code S1015. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S1015 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S1015 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S1015 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S1015 billed for date of service August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal epidural steroid injections (64483, 
64484). 
 
You asked the Plan to pre-approve injections. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the documentation provided does not indicate 
50% sustained improvement for three months from first set of injections. There is no documentation of a 
different approach, level and/or medication for the requested second set of injections. 
 
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 injections. 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 low back pain. She is taking Gabapentin and Tramadol for pain. On 
July 6, 2023, she had transforaminal epidural steroid injections at the right L2-L3 and L3-L4. The LCD criteria 
requires that the enrollee achieve three months of at least 50% pain relief. This was not achieved and therefore, 
the request is deemed 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve transforaminal epidural steroid injections (64483, 64484).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the 17 units of code 88341 provided on February 14, 2023, 
corresponding to 17 antibody stains beyond the first stain, performed on pericardial fluid. 
 
You asked the Plan to pay for the 17 units of code 88341. You say that this should be paid as billed.  The Plan 
denied your request. The Plan says that while the documentation does support that excess units were provided, 
they have not given any specific rationale as required by the policy as to why additional units needed to be 
performed. 
 
Please note: The Plan indicates that this is not a medical necessity decision, because the units can only be paid 
if there is a specific rationale given. This is not stated in the rules. The rules only indicate that a medical review 
must find the excess units to be medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that for MUEs with an MAI of 3, the additional units can 
be paid only if the excess units were actually provided, were correctly coded, and were 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 17 units of code 88341. Our reviewer 
says that the records support that the number of stains performed were medically necessary.  Our physician 
reviewer found the enrollee is a female with poorly differentiated non-small cell carcinoma with malignant 
pericardial effusion. Given the malignant pericardial effusion with a poorly differentiated carcinoma, it would 
take several different types of immunohistochemical stains to identify the origin of the primary cancer causing 
the pericardial effusion for treatment planning. 
 
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 17 units of code 88341 have been met. Therefore, we decided that the Plan 
has to pay for the 17 units of code 88341 provided on February 14, 2023, corresponding to 17 antibody stains 
beyond the first stain, performed on pericardial fluid.  
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper eyelid blepharoplasty. 
 
You asked the Plan to pre-approve a blepharoplasty. You say that the enrollee needs this procedure. The Plan 
denied your request. The Plan says the medical criteria for a blepharoplasty have not been met. 
 
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 blepharoplasty. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the marginal reflex distance (MRD) is 5 mm bilaterally, as documented in the 
progress note and photos provided. This degree of MRD is not considered visually significant and does not 
meet the criteria for a blepharoplasty. 
 
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 blepharoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an upper eyelid blepharoplasty.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the lodging expenses (S9976) and sales 
tax (S9999) provided by an out-of-country provider from December 24, 2022, to February 22, 2023. 
 
You asked the Plan to provide reimbursement for the lodging expenses and sales tax. You say that you are 
requesting reconsideration of the denied reimbursement. The Plan denied your request. The Plan says the 
lodging expenses do not meet the urgent or emergent criteria. The Plan also says the billed codes are invalid for 
Medicare purposes.  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 Plan contract says that emergency 
services are covered if you are traveling outside of the United States for less than six months. 
 
The record shows during your recovery you stayed at a residential lodging facility. This accommodation does 
not meet the emergent criteria. We also find that procedure codes S9976 and S9999 have a Status Indicator of I 
on the Physician Fee Schedule. This means that procedure codes S9976 and S9999 are not valid for Medicare 
purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9976 and 
S9999 have not been met. Therefore, we decided that the Plan does not have to provide reimbursement for the 
lodging expenses (S9976) and sales tax (S9999) provided by an out-of-country provider from December 24, 
2022, to February 22, 2023.