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

 
We decided that the Plan has to pay for therapeutic radiology simulation-aided field setting; simple  
(code 77280) provided on May 10, 2023. 
 
You asked the Plan to pay for therapeutic radiology simulation-aided field setting; simple (code 77280). You 
say that the claim was denied in error and states prior claims have been paid and this claim should have also 
been paid. The Plan denied your request. The Plan says that therapeutic radiology simulation-aided field 
setting; simple is not medically necessary. A review of the current medical literature shows that the evidence is 
insufficient to determine long-term efficacy and safety data to support the routine use of electronic surface 
brachytherapy. 
 
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 pay for therapeutic radiology simulation-aided field 
setting; simple (code 77280). Our reviewer says that the requested therapeutic radiology simulation-aided field 
setting; simple (code 77280) is considered medically reasonable and necessary in this case. Our physician 
reviewer found that most often, simple simulations utilize image guidance (IGRT) to verify set-up prior to 
treatment. After that, IGRT is a daily imaging that is used to improve set-up accuracy (which is similarly not 
necessary in this case though not disputed). When treating skin cancers, or any cancer, one could justify a 
simulation (either complex or simple) prior to treatment planning and a simple simulation prior to the first 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic radiology simulation-aided field setting; simple (code 77280) have 
been met. Therefore, we decided that the Plan has to pay for therapeutic radiology simulation-aided field 
setting; simple (code 77280) provided on May 10, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks.  
 
You asked the Plan to pre-approve the nerve blocks. You say that this is medically necessary to treat your knee 
pain. The Plan denied your request. The Plan says this is an experimental treatment.  
 
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 nerve blocks. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided medical records and review of the current peer-reviewed medical literature do not 
document that use of genicular nerve blocks has been shown in controlled studies in a Medicare-approved 
journal to result in long-term health benefits in patients with knee pain due to osteoarthritis.  
 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 nerve blocks have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genicular nerve blocks.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 26, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 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 81456 billed for date of service April 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 7, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 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 81456 billed for date of service April 7, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility services. 
 
You asked the Plan to pre-approve skilled nursing facility services. The Plan denied your request. The Plan 
says the Skilled Nursing Facility services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from April 10, 2023, 
through July 18, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve continued skilled nursing facility 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 the requested IRF services are medically necessary. 
The Plan denied your request. The Plan says the criteria for admission to the IRF have not been met. 
 
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 that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. While the enrollee requires treatment including physical/occupational therapy, the 
documentation does not support that he requires at least 3 hours a day /5 days a week. The enrollee could 
receive care in another setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee does not have the assistance at home 
required to maintain safety during one or more functional mobility tasks and/or activities of daily living. The 
enrollee would benefit from skilled nursing and rehabilitation services to optimize outcomes to achieve 
functional independence to safely go home and prevent re-hospitalization.  The Plan denied your request. The 
Plan says the enrollee does not show to have skilled nursing or therapy needs that need to be provided on a 
daily basis as an inpatient only status. The Plan says services required can safely be received at a different 
setting, home with home health, in residential care, or home with close follow-up with a physician. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nulojix. 
 
You asked the Plan to pre-approve Nulojix. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that drugs may be covered only if dispensed and billed to 
Medicare by the entity that actually dispenses the drug to the Medicare beneficiary, and that entity must be 
permitted under all applicable federal, state, and local laws and regulations to dispense drugs. 
 
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 Nulojix. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record indicates that the enrollee is 
receiving the requested drug as immunosuppressive therapy following a kidney transplant. The record indicates 
that the medication is being administered in the home setting and is therefore by rule from coverage. The 
elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nulojix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Nulojix.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for April 3, 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 procedure code G0482 is 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 G0482 is definitive drug testing, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, there is no documentation to 
support that 15-21 drug classes were tested. 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 
procedure code G0482 billed for April 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total knee arthroplasty.  
 
You asked the Plan to pre-approve the total knee arthroplasty. You say that the enrollee suffered skin tears that 
prohibited him from completing his sixth week of physical therapy and the enrollee should not be penalized. 
The Plan denied your request. The Plan says the total knee arthroplasty is not medically necessary. The Plan 
says the enrollee has only completed five of the six required weeks of physical therapy.  
 
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 total knee arthroplasty. Our 
reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for left knee osteoarthritis. The documentation 
regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is not evident. The enrollee has not completed a full course of physical therapy for the left knee. Also, there are 
no formal diagnostic imaging studies to corroborate significant pathology of the left knee to support the 
requested procedure. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the total knee arthroplasty.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 28, 2022, 
to January 17, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from December 28, 2022, to 
January 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left knee genicular nerve radiofrequency ablation 
(64624).  
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that the enrollee has 
chronic knee pain and has undergone other treatments without long-term improvement.  The Plan denied your 
request. The Plan says this procedure is not the standard of care for the enrollee's condition.  
 
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 genicular nerve radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found further studies are needed to evaluate the safety and 
efficacy of the requested procedure for knee osteoarthritis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve left knee genicular nerve radiofrequency ablation (64624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 billed for February 28, 2022. 
 
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 procedure code 87506 is 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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
We find that CPT code 87506 is not supported in the medical record. Specifically, the records show that more 
than 11 targets were tested and there is a more appropriate code for the services. 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 procedure code 87506 billed for February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power scooter (K0800). 
 
You asked the Plan to pre-approve the replacement power scooter. You say that the enrollee's scooter was 
stolen. You also say that the enrollee needs a replacement scooter. The Plan denied your request. The Plan says 
the request for a replacement power scooter is not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover 
repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by 
the beneficiary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the replacement power scooter have not been met. Specifically, the file indicates that certain parts 
of the power scooter were stolen. The file does not indicate that the original scooter cannot be repaired, or that 
the repairs will be more than the cost of a new one. Therefore, we decided that the Plan does not have to pre-
approve a replacement power scooter (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boost nutritional supplement (B4152). 
 
You asked the Plan to pre-approve Boost nutritional supplement. You say that you are losing weight and you 
ate more food when you were taking Boost because it gave you more energy. The Plan denied your request. 
The Plan says nutrition products taken by mouth are not covered Medicare benefits.  
 
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. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Boost nutritional supplement (B4152).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on May 10, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on May 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided medical records and review of the current peer-reviewed medical literature do not document that use of the bone marrow aspiration for bone grafting in spine surgery has been shown in 
controlled studies in a CMS-approved journal to result in long term health benefits in patients with lumbar 
spinal stenosis with neurogenic claudication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).