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

 
We decided that the Plan does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis, 
up to 1 hour (96365), intravenous infusion, for therapy, prophylaxis, or diagnosis; each additional hour (96366) 
and refilling and maintenance of portable pump (96521) provided on July 10, 2023. 
 
You asked the Plan to pay for intravenous infusion. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says codes 96365, 96366, 96521 
remain 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. 
 
 
 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 intravenous infusion. Our reviewer says that the service does 
not meet criteria for payment on this claim. Our reviewer found for code 96365; the medical record describes 
intravenous insulin treatment provided for an outpatient on July 10, 2023. In this case, there is a more specific 
Healthcare Common Procedure Coding System (HCPCS) code that should be reported for service provided. 
For code 96366, the medical record describes intravenous insulin treatment provided for an outpatient on July 
10, 2023. In this case, there is a more specific HCPCS code that should be reported for service provided. For 
code 96521, the medical record does not include documentation of refilling and maintenance of portable 
pump. Was unable to cite report, as this procedure was not found in medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intravenous infusion have not been met. Therefore, we decided that the Plan 
does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis, up to 1 hour (96365), 
intravenous infusion, for therapy, prophylaxis, or diagnosis; each additional hour (96366) and refilling and 
maintenance of portable pump (96521) provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (99213) provided on June 
13, 2023. 
 
You asked the Plan to pay for an office or other outpatient visit. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that F25.0 has an Excludes1 note in relation to F20.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for an office or other outpatient visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an office or other outpatient visit (99213) provided on June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee orthosis (L1851). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this request does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that a knee orthosis is covered if there is evidence of 
knee instability. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has knee arthritis, which is listed amongst the group 4 codes referred to in the LCD. 
Coverage would be permitted to treat the cartilaginous damage caused by osteoarthritis on its own, and some 
other form of ligamentous knee injury/instability in addition. The osteoarthritis is confirmed by the prescriber's 
clinic note from October and an x-ray from August 14, 2023, showing medical compartment narrowing. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a knee orthosis (L1851).  
 
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 laboratory services coded as 87481 and 87798 provided 
May 9, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration and 
payment in full for the test performed for the enrollee. The Plan denied your request. The Plan says the billed 
service is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Additional clinical records were requested from the provider to support the billed services. The records show 
that the Plan made multiple attempts to obtain the needed records without success. Therefore, we decided that 
the Plan does not have to pay for the laboratory services coded as 87481 and 87798 provided May 9, 2023.
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 you are very weak and have multiple issues. You say 
you need this level of care before going home. The Plan denied your request. The Plan says admission to an 
IRF 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 your nursing, medical, and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 
 not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  You continue 
to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement. 
However, the documentation does not support that you would meet the criteria for admission to an IRF.  There 
is no indication that you would require skilled rehabilitation in an IRF, participating in rehabililtation services 
15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your 
functional status.  You can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and 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 you prefer to be admitted to an IRF because you 
wish to become independent and active as quickly as possible. The Plan denied your request. The Plan says you 
have not met the criteria 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 while you are noted to have a decline in your level of function, your skilled therapy 
needs could be met in a lower level of care. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation program. There is no reasonable 
expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis with additional stabilization (L1686 and 
L2624), provided on April 11, 2023.  
 
You asked the Plan to pay for the hip orthosis with additional stabilization. You say that the items should be 
covered. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records provided do not indicate that the enrollee's hip was specifically evaluated by 
examination or with radiologic imaging, described as abnormal or painful, and there was no documented plan 
for treatment of the hip. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the hip orthosis 
with additional stabilization (L1686 and L2624), provided on April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Percepta Bronchial Genomic Classifier (81479) provided 
May 10, 2023. 
 You asked the Plan to pay for the genetic testing. You say that you are asking for reversal of the initial adverse 
determination and allow full reimbursement of the claim. The Plan denied your request. The Plan says under 
Medicare, the request 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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intermediate pretest risk of malignancy means the lung nodules measure between 10 and 30 
millimeters (mm) and/or have a 10 to 60 pack per year smoking history. High pretest risk of malignancy means 
lung nodules are larger than 30 mm and/or have a greater than 60 pack per year smoking history. In this case 
the last documented size of the lung nodules reviewed demonstrated the lung lesion to be larger than 5 
centimeters (cm) and would fall under high pretest risk, and in such case Percepta Bronchial Genomic 
Classifier would not qualify. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the Percepta Bronchial Genomic Classifier (81479) provided May 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anterior lumbar discectomy with anterior and posterior 
instrumented fusion (22612, 22614, 22842, 22853, 20930, 22558, 22585). 
 
You asked the Plan to pre-approve the services. 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the dynamic flexion/extension films are not provided in order to potentially assess the amount 
of movement (instability) at the requested surgical levels. Detailed documentation is not evident regarding 
potential impending/inevitable temporary intra-operative instability at the requested surgical levels. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. Therefore, the requested anterior lumbar discectomy with anterior and posterior instrumented 
fusion at L3-S1 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve anterior lumbar discectomy with anterior and posterior instrumented fusion (22612, 22614, 
22842, 22853, 20930, 22558, 22585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala Trio 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 device is considered experimental and investigational. 
 
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 there is insufficient evidence in the literature that this device is effective for the enrollee's tremor. 
The requested K1018 is not the standard of care for this enrollee's tremor according to current guidelines.  
 
 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 the Cala Trio device
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira. 
 
You asked the Plan to pre-approve Humira. You say that the requested drug is medically necessary to treat the 
enrollee's psoriasis. 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 Humira.  
 
Benefits for Humira 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0480, 83789) provided on March 28, 
2023. 
 
You asked the Plan to pay for drug testing services. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says these codes are not supported for 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity 
testing. 
 
In this case, the CPT Code Manual definition of code G0480 is drug test(s), definitive, qualitative or 
quantitative, all sources, includes specimen validity testing; 1-7 drug class(es), including metabolite(s) if 
performed. We find that CPT code G0480 is not supported in the medical record. Specifically, the records 
provided show that drugs from more than 7 drug classes were tested in this case. In addition, we find that the 
testing described by code 83789 is specimen validity testing, which is not separately payable. 
 
Based on this information, we decided that Medicare rules for coverage of drug testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for drug testing services (G0480, 83789) 
provided on March 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight MTHFR testing provided on March 16, 2023. 
 
You asked the Plan to pay for the GeneSight MTHFR testing. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the clinical utility of MTHFR testing is 
uncertain. 
 
We looked at the file and Medicare rules. The services at issue were testing for MTHFR gene. This is 
specifically not covered. Based on this information, we decided that Medicare rules for coverage of the 
GeneSight MTHFR testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
GeneSight MTHFR testing provided on March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that experimental and investigational devices are not covered. 
 
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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that regardless of the Plans own internal policies regarding the technology, the fact is that Medicare has 
and does cover powered orthoses such as this on a case-by-case basis. This technology is not unproven in the 
medical literature. In fact, it is generally accepted as part of the standard of care among the medical community 
specializing in the treatment of patients like this one precisely because it has been proven to be helpful for 
permitting functional restoration of chronically paretic upper extremities in a way that is usually not possible 
through other therapeutic alternatives. This specific medical record supports the enrollee's individual need for 
the requested orthosis. Additionally, the plan must arrange for necessary specialty care at in-network cost-
sharing levels, regardless of whether or not that care can be provided by its own network of providers. In this 
case, because this provider is the only provider who can provide the services required, the plan must cover their 
services and provide a gap exception.  
 
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 been met. Therefore, we decided that the Plan has to pre-
approve the MyoPro Motion G orthosis.  
 
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: 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 without IRF services your quality of life would 
decrease. The Plan denied your request. The Plan says the request 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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.