Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to 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 provided by 
Health Plan. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
tertiary level of care provider. 
 
You asked the Plan to pre-approve the continuation of care with an OON provider. You say that you want to 
continue care with the doctor who initiated your treatment. The Plan denied your request. The Plan says this 
would be considered a routine follow-up office visit 2 years after previous treatment and is not considered 
urgent or emergent. The Plan says that there are network endocrinologists who can treat your condition. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of care with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found there is no specific medical rationale for continued out-of-network Endocrinology care and 
follow-up. The enrollee is not currently receiving any active treatment and/or medical management of their 
condition that makes it medically necessary for this enrollee to continue care with the OON provider as 
requested. There is not anything unique about this enrollees condition that would make it medically necessary 
for her to continue care with the OON provider. The Plan has shown that they have in-network specialists who 
have the qualifications and expertise necessary to meet the current medical Standards of Care required for 
treatment of the enrollees condition. The enrollees medical management and/or follow-up care can be safely 
transitioned to an in-network specialist at this time. The tertiary level of care where this requested OON 
provider services is not a medically necessary level of care for the enrollee. The non-tertiary level of care, 
which the Plan is offering coverage for, is sufficient. 
 
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 continuation of care with an OON provider have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
tertiary level of care provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 20, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 laboratory services 
provided on April 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. 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 Mounjaro.   
Benefits for the medication 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology, gross and microscopic examination 
(tissue exam) (88305) provided on June 22, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
You asked the Plan to pay for the tissue exam. You say that medical records support the services provided and 
the claim should be paid. The Plan denied your request. The Plan says code 88305 was denied because it was 
billed in an outpatient facility Place of service (POS) and the treating physician specialty was not a pathologist 
or laboratory physician.   
 
We find that CPT code 88305 was billed with modifier 26 which indicates a professional component of a 
service. However, the records show that a pathologist performed the surgical pathology and not the billing provider at issue in this case. Based on this information, we decided that Medicare rules for coverage of the 
tissue exam have not been met. Therefore, we decided that the Plan does not have to pay for the surgical 
pathology, gross and microscopic examination (tissue exam) (88305) provided on June 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 21, 2022, billed 
with codes 81121, 81194, 81206, 81270 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. 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 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis 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 
February 21, 2022, billed with codes 81121, 81194, 81206, 81270 and 81351.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
July 19, 2023, and billed with codes 87500, 87652, 87640, 87798, and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says unbundling of lab codes for PCR panel testing is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on July 19, 2023, and 
billed with codes 87500, 87652, 87640, 87798, and 87481.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the upper extremity 
joint. 
 
You asked the Plan to pre-approve the MRI scan. You say that advanced imaging is being requested for 
possible evaluation of surgical intervention. The Plan denied your request. The Plan says that the enrollee has 
not completed six weeks of provider directed treatment. 
 
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. We find that the Plan has not given medical records to show that the denial is 
valid. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the 
upper extremity joint.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on July 14, 2023.  
You asked the Plan to pay for the eyeglasses. You say that the item should be covered. The Plan denied your 
request. The Plan says the Plan benefit for this service has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. If the eyewear you purchase costs more than $300, you will be responsible for the difference.  
 
We looked at the file and the Plan's rules. The request exceeds the benefit limit for this service. Based on this 
information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyeglasses purchased on July 14, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice services rendered from March 29, 2023, to 
March 31, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that hospice claims must be billed with one of four 
level of care revenue codes. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with a required level of 
care code. 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 pay for the hospice services rendered from 
March 29, 2023, to March 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure addresses vertebrogenic 
pain by addressing a gap in the treatment algorithm for those suffering from chronic low back pain. You also 
say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. 
The Plan says this is experimental and therefore is not covered. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes without facet degenerative joint disease or stenosis. The  
 reviewer found that the cause of the enrollee's pain is not clear. Therefore, the reviewer found that the 
requested Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29580 provided on January 19, 2023. 
 
You asked the Plan to pay for procedure code 29580. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the code 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. 
 
In this case, the CPT Code Manual definition of code 29580 is strapping; unna boot. 
 
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 29580. Our reviewer says that the records do 
not support the billed service. Our reviewer found the documentation provided does not document that 
strapping was performed. 
 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 29580 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 29580 provided on January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the enteral formula, nutritionally incomplete/modular 
nutrients (B4155). 
 
You asked the Plan to pre-approve the enteral formula. You say that you have neuropathy and needs a 
wheelchair. You are very weak and needs this nutrition just to have enough energy to walk. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for special nutrient formulas. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. The records show that the 
enrollee the enrollee receives Meals on Wheels and has a personal care attendant who prepares meals, is able to 
eat regular food and has gained weight. The records also show the enrollee already uses Ensure and Liqucel. Therefore, we decided that the Plan does not have to pre-approve the enteral formula, nutritionally 
incomplete/modular nutrients (B4155).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. 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 Prednisone.   
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) under pressure (G0277) and 
physician attendance and supervision of HBO therapy (99183). 
 
You asked the Plan to pre-approve HBO under pressure and physician attendance and supervision. You say that 
the enrollee has a severe wound on their foot with potential loss of leg and limb, and you do not agree with the 
decision. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber and is covered for diabetic wounds of the lower extremities 
in patients who meet the criteria listed in the Medicare rules section of this letter. 
 
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 HBO under pressure and physician 
attendance and supervision. Our reviewer says that the criteria for coverage have not been met. Our physician 
reviewer found the provided records in this case document a diabetic wound of the right lower extremity of 
Wagner grade 4. Provided records do not document failure of an adequate course of standard wound therapy; 
standard wound therapy in this case documents the total wound volume has decreased from 50.4 cubic 
centimeters on October 26, 2023 to 22.58 cubic centimeters on November 28, 2023.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO under pressure and physician attendance and supervision have not been 
met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) under 
pressure (G0277) and physician attendance and supervision of HBO therapy (99183).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular artery embolization. 
 
You asked the Plan to pre-approve a genicular artery embolization. You say that this is a covered procedure 
under Medicare. You say that the enrollee has tried NSAIDS and conservative therapy without improvement. 
You also say that the enrollee is refusing knee surgery. The Plan denied your request. The Plan says genicular 
artery embolization to treat knee osteoarthritis is unproven and 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 a genicular artery embolization. Our 
reviewer says that the requested genicular artery embolization is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered experimental therapy and it is the 
subject of ongoing clinical trials. Therefore, the reviewer found that the requested genicular artery embolization is not medically reasonable and 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 a genicular artery embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a genicular artery embolization.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pegloticase. 
 
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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of chronic 
tophaceous gout. The records do not indicate that his condition has been refractory to conventional therapy. 
The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of the drug 
in the enrollee's clinical situation. The services are therefore not reasonable and medically necessary or safe and 
effective 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pegloticase.