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

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy (US-IGRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the treatment itself is not disputed in this case but rather the need for image guidance. At issue is the 
need for daily image guidance; it appears that the request is for IGRT. Usually, IGRT is used when critical 
structures are abutting or in close proximity to the target that is being treated to high doses. This situation does 
not apply to this enrollee for which the target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. Certainly, 
using ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is Food and 
Drug Administration (FDA) approved for use with ultrasound though that in and of itself does not mean that 
daily imaging is necessary but simply that the device was designed to incorporate this functionality. Therefore, 
to bill for daily simple simulations (77280- also requested in this case) and/or IGRT for a technology for which 
need has not been established by published data or supported by consensus guidelines (many of which 
recommend against treatment with these devices in general- citations below) is not 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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound-guided radiation therapy (US-IGRT).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an alignable system (L5910) and vertical shock reducing pylon 
(L5988). 
 
You asked the Plan to pre-approve alignable system and shock reducing pylon. You say that the enrollee has 
been a K3 ambulator for over a year now. You say that the enrollee has stairs to enter their home. You also say 
that this should be approved. The Plan denied your request. The Plan says that the notes do not show why your 
current alignable system cannot be used with the new prosthesis. The Plan also says the notes do not show why 
the advanced pylon is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pre-approve alignable system and shock reducing 
pylon. Our reviewer says that the requested prosthetic components are medically necessary. Our physician 
reviewer found the provided documentation clearly supports that the enrollee is a K3 ambulator. The reviewer 
also found that it creates an undue burden on the enrollee, which is not supported nor called for in Medicare 
policy, to demand that the record specifically address a small subpart of the overall approved service which 
neither a prosthetist nor a prescribing physician would think to speak to in the creation of authentic medical 
records. Therefore, the reviewer found that the requested prosthetic components are medically reasonable and 
necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of alignable system and shock reducing pylon have been met. Therefore, we 
decided that the Plan has to pre-approve an alignable system (L5910) and vertical shock reducing pylon 
(L5988).  
 
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: Favorable

 
We decided that the Plan has to pay for FoundationOne Liquid CDx (0239U) provided on February 2, 2022. 
 
You asked the Plan to pay for FoundationOne Liquid CDx. You say that this test was medically necessary. The 
Plan denied your request. The Plan says that this claim is denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a clear reason for denial in this case, and 
this reason has not been supported with evidence and a relevant citation. The Plan has also failed to provide a 
copy of the original claim. The Plan has not substantiated their denial in this case. In addition, we find that the 
specific test at issue is considered covered by the Molecular Diagnostics (MolDX) contractor, which applies to 
services provided in many states and requires that the test meet certain criteria. Therefore, we decided that the 
Plan has to pay for FoundationOne Liquid CDx (0239U) provided on February 2, 2022.  
 
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 i-Factor allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is limited published, large-scale, 
long-term peer-reviewed literature that shows i-Factor allograft to be an effective and/or safe treatment for the 
noted pathology. Further studies are needed to corroborate that the requested allograft would be as safe or better than standard allograft procedures. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested i-
Factor allograft 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an i-Factor allograft.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99223) provided on January 5, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services should 
have been billed with an observation code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99223 is "Initial hospital inpatient or observation care, per day, for the evaluation and management of a 
patient, which requires a medically appropriate history and/or examination and high level of medical decision 
making. When using total time on the date of the encounter for code selection, 75 minutes must be met or 
exceeded". 
 
We find that CPT code 99223 is supported in the medical record. Specifically, code 99223, by definition, can 
be used for initial observation care and is appropriate in this case. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
the services (99223) provided on January 5, 2023.  
 
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 validity testing billed with code 83789 for date(s) of service 
July 7, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
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. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's needs can be met in an alternate level of 
care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99490 and 80305 billed for date of service 
September 6, 2022. 
 
You asked the Plan to pay for procedure codes 99490 and 80305. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says code 80305 is not supported by the records 
provided, and the payment for code 99490 is included in the payment for code 20552. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that significant, separately identifiable evaluation and management services performed by the same 
physician on the day of a procedure must be reported with modifier "-25" for separate payment. The rules also 
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 Medicare rules for 
coverage of procedure codes 99490 and 80305 have not been met. Specifically, code 99490 is an evaluation 
and management code which was reported on the same day as a minor surgical procedure but was not billed 
with the required modifier for separate payment/reporting. In addition, the records provided do not include the 
results of any presumptive drug screening tests. Therefore, code 80305 cannot be verified. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99490 and 80305 billed for date of service 
September 6, 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 this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's status is stable and improving. The enrollee 
is receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that 
cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a 
therapeutic advantage. The enrollee does not appear to meet the criteria for LTACH admission. 
 
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 transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer and 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic cancer screening (81317, 81292, 81298, 81295, 
81300, 81319, 81294) provided on December 1, 2022. 
 You asked the Plan to pay for genetic cancer screening. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this service was provided as a screening to an enrollee with no 
personal history of cancer; therefore, this testing is not covered by Medicare. 
 
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 screening, was 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 pay 
for genetic cancer screening (81317, 81292, 81298, 81295, 81300, 81319, 81294) provided on December 1, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve remote monitoring of physiologic parameter(s) and 
remote physiologic monitoring treatment management services (99453, 99454, 99457, 99458) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve remote monitoring. You say that the remote patient monitoring with 
spirometry for the enrollee is essential in controlling her asthma and tightly managing her chronic condition 
with a data-driven medication regimen. The Plan denied your request. The Plan says the enrollee must receive 
care from a network provider. 
 
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 
remote monitoring of physiologic parameter(s) and remote physiologic monitoring treatment management 
services (99453, 99454, 99457, 99458) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says 3D conformal radiation therapy (3D-CRT) would be approved if requested. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that for this enrollee, there is no comparison plan provided. The policy requires demonstration of need to 
justify IMRT. Without a comparison plan, for a condition for which IMRT is arguably not standard for routine 
use, this cannot be considered 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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intensity-modulated radiation therapy (IMRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99343 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code 99343. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says payment for code 99343 is bundled into 
payment for code 99344. 
 
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 99343 is a column II code to column I code 99344; however, 99343 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99343. Our reviewer says that procedure 
code 99343 does not meet criteria for payment. Our reviewer found that the medical record submitted includes 
documentation of one evaluation and management service. There is insufficient documentation to verify that a 
second evaluation and management service was provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99343 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99343 billed for date of service August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the enrollee has bronchiectasis and meets the 
coverage criteria. The Plan denied your request. The Plan says the request is not medically necessary because 
the member does not have CT scan confirmed bronchiectasis, cystic fibrosis or a neuromuscular disease 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.   
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 HFCWOD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the record indicates that the enrollee has chronic obstructive pulmonary disease. 
The CT scan provided does not indicate the presence of bronchiectasis. The enrollee does not have cystic 
fibrosis or one of the neuromuscular diseases required for coverage of the requested service.  The elements of 
the coverage criteria are not satisfied. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).