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

 
We decided that the Plan does not have to pay for a needle measurement of electrical activity in arm or leg 
muscles, limited study (95885) provided on June 16, 2021. 
 
You asked the Plan to pay for the electromyography. You say that the claim should be paid as billed. The Plan 
denied your request. The Plan says current procedural terminology (CPT) code 95885 remains not supported. 
 
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 95885 is a needle electromyography, each extremity, 
with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity 
study; limited. 
 
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 the electromyography. Our reviewer says that the 
documentation does not support procedure code 95885.  Our reviewer found that the procedure report describes 
pedicle screw stimulation, which cannot be verified as nerve conduction study.  In this case, the criteria for 
current procedural terminology (CPT) code 95885 have not been met, and therefore would not be covered.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the electromyography have not been met. Therefore, we decided that the Plan 
does not have to pay for a needle measurement of electrical activity in arm or leg muscles, limited study 
(95885) provided on June 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an ILR. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an implantable loop recorder is considered reasonable 
and necessary when syncope (fainting) is thought to be cardiac related and an external Holter monitor (heart 
rate and rhythm monitor) has been tried and failed to detect an abnormal heart rhythm. 
 
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 an ILR. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the patient had no history of atrial fibrillation, 
nor were there any significant cardiac arrhythmias documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR) (33285).
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 the requested LTACH admission is the 
best option for the enrollee to receive the best care and prevent readmission. The Plan denied your request. The 
Plan says the enrollee does not meet the requirements for admission to the 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has improved medically and can receive further care at the current acute care hospital or a lower level of care when deemed appropriate.   
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (96132, 96138, and 96139). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the 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 neuropsychological testing. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the patient is not 
showing severity of symptoms that would warrant this type of diagnostic treatment and is therefore not 
medically necessary or reasonable since the provider is requesting screening tests not considered 
neuropsychological testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing (96132, 96138, and 96139).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve Freestyle Libre 3. You say that the manufacturer advertises this equipment. 
The Plan denied your request. The Plan says this device is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the opioid treatment services provided on December 26, 2022. 
 
You asked the Plan to pay for the billed services. You say that the provider is enrolled in the OTP program. 
The Plan denied your request. The Plan says that the code must be billed on the facility claim. 
 
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. 
 
We looked at the file and the rules. The Plan incorrectly states that the claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed based on billing guidelines. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request. 
Therefore, we decided that the Plan has to pay for the opioid treatment services provided on December 26, 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous (IV) Ketamine treatment. 
 
You asked the Plan to pre-approve IV Ketamine treatment. You say that IV Ketamine treatment is medically 
necessary. The Plan denied your request. The Plan says IV Ketamine treatment is experimental. 
 
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 IV Ketamine treatment. Our reviewer 
says that the requested IV Ketamine treatment is not considered medically reasonable and necessary. Our 
physician reviewer found that based on the records and the literature provided by the manufacturer, this 
procedure is not indicated by the Food and Drug Administration (FDA) for the treatment of Depressive 
Disorders. The use of this procedure is considered off label. Based on review of the records provided and the 
literature provided on the use of this procedure, it does not appear that this procedure is considered medically necessary for the treatment of depressive disorder and is not considered in my opinion within the treatment 
medical necessary due to no FDA indication and would be considered experimental/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 IV Ketamine treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve IV Ketamine treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has dementia and is a fall risk. The Plan 
denied your request. The Plan says the IRF admission was denied as 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 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. 
 
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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 28, 2022, billed with 
codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, and 
87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that medical records were provided. 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 
code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 28, 2022, billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 
87651, 87653, 87661, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 You asked the Plan to pre-approve sclerotherapy. You say that the requested sclerotherapy is medically 
necessary. The Plan denied your request. The Plan says the requested sclerotherapy does not meet the Medicare 
LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 sclerotherapy. Our reviewer says that 
the requested sclerotherapy is not considered medically necessary in this case. Our physician reviewer found 
that the documentation does not meet the Medicare coverage criteria and does not support the treatments in 
question. The coverage criteria require that the enrollees symptoms be due to the varicose veins being 
treated. In this case the enrollee is a 75-year-old with leg ulcers, numerous risk factors for peripheral artery 
disease, and a documented history of peripheral artery disease. While there is documentation of a right upper 
extremity arterial pulse exam and a right upper extremity noninvasive vascular exam, there is no assessment of 
arterial perfusion to the lower extremities documented in the materials provided. Therefore, the documentation 
does not meet coverage criteria and does not support the appropriateness/medical necessity of venous 
intervention. For sclerotherapy to be considered medically necessary, the above criterion regarding absence of 
peripheral artery disease needs to be met and there needs to be documentation that the enrollee remains 
symptomatic despite conservative efforts for a period of at least six (6) weeks following treatment of the 
truncal (saphenous) reflux. In summary, the review would not recommend coverage of any venous related 
procedures without an assessment of lower extremity arterial perfusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy of telangiectasia and incompetent veins (code 36470).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 27, 2023, to 
February 17, 2023, by an OON provider. 
 
You asked the Plan to pay for home health services. You say that prior authorization was approved for these 
services. The Plan denied your request. The Plan says that these services are not covered by an out-of-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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract also says that the enrollees POS benefit does 
not apply to OON home health services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
home health services provided on January 27, 2023, to February 17, 2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 billed for date of 
service October 25, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653, and 87798. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 87481, 87653, and 87798 is 
bundled into payment for code 87801. 
 
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 codes 
87481, 87653, and 87798 are column II codes to column I code 87801. 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 codes 87481, 87653, and 87798 
billed for date of service October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you have neuropathy in your hands and finger 
pain from traditional finger pricking. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retinal imaging (92250) provided on January 12, 2023. You asked the Plan to pay for the imaging. You say that the Plan should pay for the retinal imaging. The Plan 
denied your request. The Plan says that this service is not covered by Medicare or the Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. This service is not covered by the Plans vision 
benefits.  
 
We looked at the file and the Plan's rules. Retinal imaging (92250) is not a covered service under your 
supplemental vision benefit. Therefore, we decided that the Plan does not have to pay for retinal imaging 
(92250) provided on January 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on November 7, 2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was not billed 
with the appropriate DEX Z-code. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A57526. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing provided 
on November 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has had a significant change from their 
baseline. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for an 
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 that the documentation does not support the necessity for admission to an IRF. The 
complexity of the enrollee's nursing, rehabilitation, and medical needs does not require an acute hospital 
inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While the enrollee may 
benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be provided in a 
lower intensity and alternate setting such as in a skilled nursing facility (SNF) or continue at home with 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tertiary level ophthalmology care. 
 
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 tertiary level of care 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 these services. Our reviewer says that 
the tertiary level of care is not medically necessary. Our physician reviewer found the enrollee has a history of 
vitreous degeneration, retinal hole, and corneal pannus of the left eye. Per the eye examination notes, the 
conditions have been very stable without any current recommendations or foreseeable need for intervention. 
Routine eye surveillance can be equally managed by a qualified in-network, non-tertiary ophthalmologist. 
 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 tertiary level ophthalmology care.