Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio device (K1018, K1019). 
 
You asked the Plan to pre-approve a Cala Trio device. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the clinical value and effectiveness of the Cala 
trio device in the setting of essential tremor have not been demonstrated in the peer-reviewed literature. 
Medical studies have not proven this service/item is helpful for the treatment of the enrollee's health problem. 
 
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 Cala Trio device. 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 a diagnosis of essential tremors. There is insufficient evidence in the 
literature that this device is effective for the enrollee. The requested device 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 a Cala Trio device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio device (K1018, K1019).
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 enrollee has strong criteria including 
aggressive ventilator weaning with medical management and is stable for discharge to the LTACH level of 
care. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for care in an 
LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder arthroplasty (23472) provided on February 16, 
2023. 
 
You asked the Plan to pay for the shoulder arthroplasty (23472). You say that an assistant surgeon is required, 
and the provider should be paid for their time. You say that the claim should be reviewed and reprocessed for 
payment. The Plan denied your request. The Plan says a registered nurse first assistant (RFNA) is not an 
eligible assistant surgeon. 
  The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the shoulder arthroplasty (23472) 
provided on February 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (L0464) provided on September 18, 2022. 
 
You asked the Plan to pay for the back brace (L0464). You say that the item should be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the back brace (L0464) 
provided on September 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
first 2 vertebral bodies, lumbar or sacral (64628) and thermal destruction of intraosseous basivertebral nerve, 
each additional vertebral body, lumbar or sacral (64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that you are requesting reconsideration due 
to medical necessity. The Plan denied your request. The Plan says the requested procedure does not meet the 
requirements for approval. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) provided does not corroborate modic changes 
at all of the requested surgical levels. Additionally, there were/are multiple plausible pathologic sources of 
significant pain generation. The chronic low back pain localized to the central lumbar spine, the intact spinal 
motion (in all directions), and intact neurologic exam were/are all non-specific to any pathologic entities. 
Overall, documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the 
spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. 
Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Intracept intraosseous basivertebral nerve ablation at L3, L4, L5, and S1, in this case, 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, first 2 vertebral bodies, 
lumbar or sacral (64628) and thermal destruction of intraosseous basivertebral nerve, each additional vertebral 
body, lumbar or sacral (64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service March 6, 
2023. 
 
You asked the Plan to pay for procedure code A4239. The Plan denied your request. The Plan says procedure 
code A4239 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code A4239 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4239 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4239 billed for date of service March 6, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 29876 rendered on February 16, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 
services at issue in this case were supported by the medical records. Our physician reviewer found that the 
enrollee was being treated for a complex tear of the lateral meniscus of the left knee. The enrollee underwent an 
arthroscopic evaluation and arthroscopic partial medial and lateral meniscectomy with arthroscopic 
chondroplasty debridement of the medial femoral condyle and synovitis on 2/16/23. The procedure details cite 
some mild to moderate amount of synovitis, which was subsequently debrided from the anterior compartment 
along the medial AND lateral gutters. This indicates synovectomy was performed on two compartments (the 
anterior 'portion' of the medial AND lateral compartment/gutters. Therefore, the records support CPT 29876 as 
a separate and distinct procedure from CPT 29880. 
 
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 pay for 
procedure code 29876 rendered on February 16, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74174 billed for date of service April 26, 
2022.  
 
  You asked the Plan to pay for procedure code 74174. You say that the service was billed with the professional 
component and there are no bundling issues found. You say that the attached reports should be reviewed, and 
the claim sent back for reconsideration of payment. The Plan denied your request. The Plan says payment for 
code 74174 is bundled into payment for code 75635. 
 
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 74174 
is a column II code to column I code 75635 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 74174 billed for date of service April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the Foundation One CDx liquid biopsy (0239U) provided 
March 21, 2023.  
 
You asked the Plan to pay for  the genetic testing. You say that FoundationOne LiquidCDx was ordered by the 
treatment physician because the tests were needed to help determine the course of treatment or this enrollee. 
The Plan denied your request. The Plan says under Medicare guidelines, this testing is not medically necessary 
as the submitted information does not indicate advanced or metastatic cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records do not show either recurrent, relapsed, refractory, 
metastatic, or advanced stage III or IV cancer or that the enrollee has decided to seek further treatment. 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 Foundation One CDx liquid biopsy (0239U) 
provided March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 19, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing is reasonable and necessary and 
Medicare-covered. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  collection of venous blood by venipuncture (36415) 
provided on April 12, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that the lab must see all patients in the nursing 
home that need care. The provider has no option to determine which patient they want to perform services on. 
The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 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 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. The Plan did not pre-approve the 
item/service at issue. 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  collection of venous blood by venipuncture 
(36415) provided on April 12, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF genetic panel (81455) provided February 1, 
2023. 
 
You asked the Plan to pay for the genetic testing. You say that denial of this claim based on failure to obtain 
prior authorization is not justifiable in this instance. The Plan denied your request. The Plan says the requested 
test is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Tempus xF has not had FDA approval or clearance as a companion 
in vitro diagnostic or an FDA-approved or -cleared indication for use in this enrollees cancer.  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 Tempus xF genetic panel (81455) provided February 1, 
2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 You asked the Plan to pre-approve the drug. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this request does not meet the plan's Part B step therapy criteria for the requested 
viscosupplement device. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee has osteoarthritis of the knee. The requested medication is a new start.  The 
provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. 
The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from 
the plan's preferred step one alternative. 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81225, 81226, 81227, 81231, 81232, 81240, 
81241, 81291, 81306, 81328, 81335, 81238) provided on January 31, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, and 
81238 are not supported in the medical record. Specifically, multiple unbundled codes were submitted for a 
single panel. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81225, 81226, 81227, 
81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81238) provided on January 31, 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 the enrollee meets Medicare criteria and will benefit 
from acute inpatient rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your 
request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthesis outer cover (L5962). 
 
You asked the Plan to pre-approve the prosthesis outer cover. You say that this feature is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems (L5962) are 
covered when the records show that the patient has special needs for protection against unusually harsh 
environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of 
protection that is afforded by a standard cover. 
 
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 prosthesis outer cover. Our reviewer 
says that the requested cover is not medically necessary. Our physician reviewer found the documentation does 
not support that the patient has special needs for protection against unusually harsh environmental situations. 
The standard cover should meet the enrollee's needs. 
 
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 prosthesis outer cover have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a prosthesis outer cover (L5962).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81479) provided on June 24, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this test was medically necessary and was 
reported appropriately. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing (81479) 
provided on June 24, 2022.