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

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that you are in a lot of 
pain because of an arthritic condition. Your provider has recommended that you have a radiofrequency ablation 
on your right knee. The Plan denied your request. The Plan says the records do not show that your doctor has 
requested a procedure that has sufficient evidence of safety and efficacy and is therefore not the standard of 
care. 
 
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 a genicular nerve block is experimental and 
investigational for knee pain. You do not meet criteria for approval of this 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 genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches 
including imaging guidance, when performed (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on December 29, 2022. 
 
You asked the Plan to pay for the office visit (99213). You say that the service 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 office visit (99213) 
provided on December 29, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) targeted 
sequence analysis (eg, exons 12 and 13) (81279), MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, 
myeloproliferative disorder) gene analysis; sequence analysis, exon 10 (81339), MPL (MPL proto-oncogene, 
thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; common variants (eg, W515A, 
W515K, W515L, W515R) (81338), and CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, 
common variants in exon 9 (81219). 
 
You asked the Plan to pre-approve JAK2, MPL gene analysis; sequence analysis, MPL gene analysis; common 
variants, and CALR. You say that the services are necessary. The Plan denied your request. The Plan says that 
medical necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 JAK2, MPL gene analysis; sequence 
analysis, MPL gene analysis; common variants, and CALR. Our reviewer says that the requested items/services 
are considered medically reasonable and necessary in this case. Our physician reviewer found you have 
potential polycythemia vera, so the genetic testing being requested is medically necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of JAK2, MPL gene analysis; sequence analysis, MPL gene analysis; common 
variants, and CALR have been met. Therefore, we decided that the Plan has to pre-approve JAK2 (Janus kinase 
2) (eg, myeloproliferative disorder) targeted sequence analysis (eg, exons 12 and 13) (81279), MPL (MPL 
proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; sequence analysis, 
exon 10 (81339), MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene 
analysis; common variants (eg, W515A, W515K, W515L, W515R) (81338), and CALR (calreticulin) (eg, 
myeloproliferative disorders), gene analysis, common variants in exon 9 (81219).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services (99291) provided on March 15, 2023. 
 
You asked the Plan to pay for practitioner services. You say that you disagree with the denial and have 
submitted medical records for review of the denied claim. The Plan denied your request. The Plan says code 
99291 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
 
 
 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 practitioner services. Our reviewer says that the service does 
not meet criteria for payment on this claim. Our reviewer found that medical documentation notes critical care, 
but the documentation did not verify that any critical care was given, or any life sustaining treatment was 
given. Critical care evaluation and management coding could not be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of practitioner services have not been met. Therefore, we decided that the Plan 
does not have to pay for practitioner services (99291) provided on March 15, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Medicare Part B prescription drugs 
provided on August 30, 2023. 
 
You asked the Plan to waive the coinsurance for the Medicare Part B prescription drugs. You say that the cost 
share is wrong. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the Medicare Part B prescription drugs. This item/service 
falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the Medicare Part B prescription drugs provided on August 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95822-26 and 95999 (2 units) provided 
August 17, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 95822 is extracapsular cataract removal with insertion of 
intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (for example, irrigation and 
aspiration or phacoemulsification); without endoscopic cyclophotocoagulation. The definition of code 95999 is 
unlisted neurological or neuromuscular diagnostic procedure. 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer found the code, 95822-26 
(electroencephalogram (EEG) in sleep/coma) was submitted for this date. However, the enrollee was not 
sleeping or in a coma and was awake, so the code, 95816 would be more appropriate for this procedure based 
on the provided documentation. The code, 95999 x 2 units was also provided for the above date. However, the 
documentation describes train of four monitoring was performed which does not fit the requirements for code 
95999. Therefore, the documentation does not sufficiently support the codes, 95822 or 95999 for the date 
August 17, 2022. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 95822-26 and 95999 (2 units) provided August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 20, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
not approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on June 20, 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 lab panel provided on August 22, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one unit of one code. 
 
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 lab panel provided on August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), intavenous infusions (96365, 96366) 
and portable pump refill and maintenance (96521) provided on June 22, 2023. 
 
You asked the Plan to pay for the office visit (99214), intavenous infusions (96365, 96366) and portable pump 
refill and maintenance (96521). You say that the services were 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 office visit (99214), 
intavenous infusions (96365, 96366) and portable pump refill and maintenance (96521) provided on June 22, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on July 3, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the records support an appropriate history and physical were obtained; However, testing for a standard medical 
clearance was performed and the medical decision making was not of high complexity. As such, the billing of 
CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on July 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet-rich plasma injections.  
 
You asked the Plan to pre-approve platelet-rich plasma injections. You say that you experience pain in your 
knees that needs to be treated urgently. The Plan denied your request. The Plan says platelet rich plasma 
injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that platelet-rich plasma injections are covered when the 
criteria listed in the Medicare rules section of this decision are met. 
 
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 platelet rich plasma injections. Our 
reviewer says that the requested platelet rich plasma injections are not considered medically reasonable and 
necessary. Our physician reviewer found that according to the Medicare coverage criteria, larger controlled 
studies comparing PRP with placebo and alternatives other than hyaluronic acid (HA) are needed to determine 
the efficacy of PRP for knee osteoarthritis. Further studies are also needed to determine the optimal protocol 
for delivering PRP.  At present, the evidence is insufficient to determine the effects of PRP on health outcomes 
for osteoarthritis. The review has determined that the platelet-rich plasma injections at issue in this case, do not 
meet the Medicare coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of platelet-rich plasma injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve platelet-rich plasma injections.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that you require additional skilled nursing services or skilled rehabilitation 
services to provide treatment that is medically necessary. You do not require additional skilled nursing or 
rehabilitation services to effectively provide treatment, care, and/or services in order to improve your condition, 
perform a maintenance program to maintain your condition and/or prevent deterioration. You have been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a necessity for the 
enrollee's care. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that 
the provided records document that the home ventilator is being requested for use in a volume targeted pressure 
support mode which is a modality that could be provided by a BiPAP device with average volume assured 
pressure support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a BiPAP 
device with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio tremor stimulator device. 
 
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. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is insufficient evidence in the 
literature that the requested Cala Trio device is effective for the patient's tremor. The services are not the 
standard of care and not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Cala Trio tremor stimulator device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the enrollee does not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found there is no documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke or any other apparent indication for an implantable cardiac monitor (ICM). In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ICM in this 
patients clinical management. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).