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

 
We decided that the Plan does not have to pay for infrared therapy billed with code 97026 for dates of service 
July 25, 2022, to August 9, 2022. 
 
You asked the Plan to pay for infrared therapy. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy is non-covered. Therefore, we 
decided that the Plan does not have to pay for infrared therapy billed with code 97026 for dates of service July 
25, 2022, to August 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (81162) provided on October 25, 2021. 
 
You asked the Plan to pay for the laboratory test. You say that this test was necessary and is supported in the 
medical record. 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 the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (81162) 
provided on October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 28, 2022, billed 
with codes 87481, 87500, 87641, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 
September 28, 2022, billed with codes 87481, 87500, 87641, 87651, 87653, and 87798.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare guidelines for services in an IRF. 
 
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 and/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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 23, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 70450 billed for date of service October 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6216 billed for date of service August 20, 
2022. 
 
You asked the Plan to pay for procedure code A6216. You say that these charges are appropriate for the 
services provided. The Plan denied your request. The Plan says procedure code A6216 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 A6216 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A6216 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A6216 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A6216 billed for date of service August 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of the Optimizer Smart 
permanent cardiac contractility modulation system (0408T). 
 
You asked the Plan to pre-approve an Optimizer Smart modulation system. You say that the requested 
outpatient surgery is needed. The Plan denied your request. The Plan says the Medicare guidelines say that this 
item or service is not medically necessary because a scientific assessment of the technique has not been 
completed and its safety and efficacy has not been established. 
 
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 Optimizer Smart modulation system. 
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 heart failure with reduced ejection 
fraction (HFrEF), LVEF: 30-35%, NY heat class 2-3, due to dilated cardiomyopathy, S/P AICD implant and 
chronic A Fib. The Optimizer (Smart Permanent Cardiac Contractility Modulation device) is an investigational 
device and currently not endorsed or recommended by any of the professional societys guidelines for 
treatment of advanced heart failure. 
 
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 Optimizer Smart modulation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve insertion or replacement of the Optimizer Smart permanent 
cardiac contractility modulation system (0408T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 14, 2022, billed 
with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 81314, 81334, 
81345, 81272 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically 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 
November 14, 2022, billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 
81351, 81209, 81314, 81334, 81345, 81272 and 81479.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 25, 2022, 
to March 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you do not believe that the admit 
date on the claim and on the NOA have to match. 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 February 25, 2022, to 
March 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0269 billed for date of service August 12, 
2022. 
  You asked the Plan to pay for procedure code G0269. You say that the medical records are attached, and the 
claim should be reviewed for payment. The Plan denied your request. The Plan says procedure code G0269 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 G0269 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code G0269 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0269 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code G0269 billed for date of service August 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0668). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that please review 
the enclosed documentation to support medical necessity of the prescribed Flexitouch PCD in treating the 
enrollee's lymphedema. The Plan denied your request. The Plan says the enrollee does not meet the LCD 
criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic 
compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0668).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 500 units of Botox every three months. 
 
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 Botox is covered when specific criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of spastic 
hemiplegia affecting left dominant side, related to viral meningitis. The Food and Drug Administration (FDA)-
approved label for Botox states to not exceed a total dose of 360 units administered in a three-month interval. 
The services are therefore 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 500 units of Botox every three months.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tint, the anti-reflective lens coating, the impact resistant 
lens, the eyeglass deluxe lens, the eyeglass frames, and the progressive lens provided on September 28, 2022. 
 
You asked the Plan to pay for the eyewear. You say that the provider did not explain your benefits correctly. 
 The Plan denied your request. The Plan says the claim processed correctly. 
 
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. The Plan covers these services when up to a $200 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan applied the $200 allowance to the eyewear 
which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the 
eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the tint, the anti-
reflective lens coating, the impact resistant lens, the eyeglass deluxe lens, the eyeglass frames, and the 
progressive lens provided on September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture visits provided from December 5, 2022, to 
December 28, 2022. 
 
You asked the Plan to pay for the acupuncture visits. The Plan denied your request. The Plan says you have 
exceeded the benefit limit. 
 The Plan contract covers a routine acupuncture benefit. The Plan says that this benefit covers up to $500 annual 
maximum for routine acupuncture. 
 
We looked at the file and the Plans rules. The file shows that the maximum $500 benefit has been reached. 
Therefore, we decided that the Plan does not have to pay for acupuncture visits provided from 
December 5, 2022, to December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
December 14, 2021. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the subsequent nursing facility care was not filed until December 29, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on 
December 14, 2021.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 pay for the testosterone cypionate (J1071), and injection (96372) 
provided on November 18, 2022. 
 
You asked the Plan to pay for the injection services. You say that you do not agree with this denial. The Plan 
denied your request. The Plan says the documentation provided does not support that the services were 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the injection services have been met. 
Specifically, the file does not support that the services in this case were medically necessary. Therefore, we 
decided that the Plan does not have to pay for the testosterone cypionate (J1071), and injection (96372) 
provided on November 18, 2022.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the member would benefit from a lower level of care, such as a skilled 
nursing facility. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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.