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

 
We decided that the Plan does not have to pay for the AVISE CTD test (0312U) provided June 22, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please see the attached documents and 
scientific evidence supporting the effectiveness of AVISE testing. The Plan denied your request. The Plan says 
this service does not meet this requirement of the member's plan of benefits and is excluded from coverage.  
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is without other clinical history provided besides having an immune 
disorder. There were no provided notes discussing symptoms, prior testing or other indications for using this 
specialized test panel. Standards of care do not include this testing panel at this time. Therefore, this request for 
AVISE CTD will be considered not reasonable or medically necessary 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the AVISE CTD test (0312U) provided June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic radiology simulation-aided field setting. 
 
You asked the Plan to pre-approve therapeutic radiology simulation-aided field setting. You say that it is 
medically necessary. The Plan denied your request. The Plan says it is 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 therapeutic radiology simulation-aided 
field setting. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the radiation is a standard approach to the treatment of 
skin cancer and is often preferred over surgery when resection is likely to result in unacceptable morbidity or 
cosmesis.  
 The use of superficial radiotherapy (SRT) or electronic brachytherapy for skin cancers that would be well-
treated with standard radiotherapy modalities such as electron therapy or orthovoltage radiotherapy. The most 
recent NCCN guidelines for basal cell and squamous cell skin cancers explicitly state There are insufficient 
long-term efficacy and safety data to support routine use of electronic surface brachytherapy.  
 
However, the treatment itself is not disputed in this case but rather at issue is the need for daily simple 
simulations. 
 
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 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve therapeutic radiology simulation-aided field 
setting.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D 25 hydroxy testing (82306) provided on April 
6, 2023. 
 
You asked the Plan to pay for the Vitamin D 25 hydroxy testing. The Plan denied your request. The Plan says 
this testing is not covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Vitamin D 25 hydroxy testing, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the Vitamin D 25 hydroxy testing (82306) provided on April 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs continued oversight care. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements. Services needed may be 
provided safely in a lower level of care. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 codes S0020 and A4550 billed for date of service 
December 28, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary for the 
treatment of the enrollee. The Plan denied your request. The Plan says the services are not 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 S0020 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0020 is not valid for Medicare purposes. We find that procedure code A4550 has a status 
indicator of B on the Physician Fee Schedule. This means that procedure code A4550 is not separately payable. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes S0020 and A4550 billed for 
date of service December 28, 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 the services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled therapy can be provided in an alternate setting. 
 
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. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for approval of a ventilator. 
 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 the service is not medically necessary. Our physician reviewer found the enrollee has COPD, obstructive 
sleep apnea, and pulmonary hypertension. The enrollee was recently hospitalized, and the arterial blood gas 
(ABG) was consistent with acute on chronic hypercarbic respiratory failure. The enrollee improved with 
BiPAP. This enrollee may benefit from BiPAP with average volume assured pressure support (AVAPS) during 
sleep as an outpatient. Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81552 billed for date of service March 14, 
2023. 
 You asked the Plan to pay for procedure code 81552. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says payment for code 81552 is bundled into 
payment for code 81445. 
 
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 81552 
is a column II code to column I code 81445. 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 81552 billed for date of service March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for July 22, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that only one hospital inpatient or observation discharge 
day management service is payable per patient per hospital stay.  
 
We looked at the file and Medicare rules. The file shows that procedure code 99239 was previously paid for the 
same provider and cannot be paid twice per one admission. Therefore, we decided that the Plan does not have 
to pay for procedure code 99239 billed for July 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets admission criteria and 
ongoing medical care warrants an LTACH level of care to achieve a "safe and sustainable discharge" per 
guidelines. The Plan denied your request. The Plan says the enrollee may continue to receive care needed at the 
current hospital. 
 
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 are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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: 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 you are requesting reconsideration 
because you fell last week from shortness of breath and were getting stronger until the treatments stopped. 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, your records do not show that you are under 
the care of a physician or other allowed practitioner who has developed and certified a plan of care. Medicare 
rules say a doctor must certify the need for home health care services. Therefore, we decided that the Plan does 
not have to pre-approve home health 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 these services are medically necessary. The Plan 
denied your request. The Plan says the enrollee is not medically stable and has not yet completed the full 
course of treatment in the referring hospital.  
 
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. Medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 (E0466). 
 
You asked the Plan to pre-approve a Life2000. 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 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 Life2000. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home 
ventilator is being requested for use during activity as an oxygen assist device. The provider states the device is 
not a true ventilator. The Life2000 is being requested for use with very low set tidal volumes (150 to 200 mL) 
which is clearly supportive and not full ventilatory support. Provided records document failure of a Trilogy 
ventilator but do not document trial and failure of a bilevel positive airway pressure (BiPAP) device with 
average volume assured pressure support (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 Life2000 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Life2000 (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets acute LTACH 
admission criteria. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary.  
 
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 that the documentation does not support that LTACH services are medically 
appropriate. The enrollee is receiving the appropriate care in the current acute care setting as provided by the 
Health Plan.  
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 LTACH services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a 100-day supply of TRUE Metrix glucose test strips (A4253). 
 You asked the Plan to pre-approve a 100-day supply of test strips. The Plan denied your request. The Plan says 
that the item was requested above normal dispensing limits as a 100-supply. The Plan also says the item is 
available as a recurring 90-day supply.  
 
The Plan follows Medicare rules. Medicare rules say that the quantity of test strips (code A4253) that are 
covered depends on the usual medical needs of the beneficiary and whether or not the beneficiary is being 
treated with insulin, regardless of their diagnostic classification as having Type 1 or Type 2 diabetes mellitus. 
 
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 100 day supply of test strips. Our 
physician reviewer found as the enrollee is having low blood glucoses (BGs), it is reasonable to give a few 
extra test strips that a 100-day supply would accomplish. Our reviewer says that this would enable the enrollee 
to be able to check their BG a bit more often when they are at risk of or experiencing symptoms of low BGs. 
 
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 100-day supply of test strips have been met. Therefore, we decided that the 
Plan has to pre-approve a 100-day supply of TRUE Metrix glucose test strips (A4253).  
 
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 procedure code 93880 billed for July 22, 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 93880 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 93880 is duplex scan of extracranial arteries; complete 
bilateral study. 
 
We find that CPT code 93880 is not supported in the medical record. Specifically, there is no documentation in 
any clinical records that the services were performed. 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 93880 billed for July 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of foot, 3 views (73630) provided on February 7, 
2023. 
 
You asked the Plan to pay for the x-ray. You say that the medical records show separate services. The Plan 
denied your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the x-ray have not been met. Code 73630 was reported with 
procedure 77075-26 billed on the same date of service from two different providers. Both providers have the 
same specialty as Radiology  Diagnostic Radiology. Both claims were billed with the same billing provider. 
Per NCCI Manual, "CPT code 77075 (Radiologic examination, osseous survey; complete (axial and 
appendicular skeleton)) includes radiologic examination of all bones. CPT codes for radiologic examination of 
other bones shall not be reported in addition to CPT code 77075. However, if a separate and distinct radiologic examination with additional films of a specific area of the skeleton is performed to evaluate a different 
problem, the appropriate CPT code for the additional radiologic examination may be reported with an NCCI-
associated modifier." A modifier was not billed on the claim to represent the services as separate/distinct.  
Therefore, we decided that the Plan does not have to pay for the x-ray of foot, 3 views (73630) provided on 
February 7, 2023.