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

 
We decided that the Plan does not have to pre-approve excision of excessive skin and subcutaneous tissue 
(includes lipectomy), arms and other areas. 
 
You asked the Plan to pre-approve the surgical service. You say that you are suffering from a lot of pain on the 
chest and a rash. You say that it is causing your depression. You say that the loose skin is irritating, painful and 
causing a rash. You also say that this is not for cosmetic reasons. The Plan denied your request. The Plan says 
the requested services are cosmetic in nature and therefore are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgical service. Our reviewer says 
that the request for removal of extra skin and subcutaneous tissue is not medically necessary. Our reviewer 
found the record indicates that the enrollee has excessive redundant skin and localized adiposity.  The record 
provided does not document that the requested service is for the prompt repair of accidental injury or to 
improve the functioning of a malformed body member. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. Therefore, the reviewer 
found that the requested removal of extra skin and subcutaneous tissue is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve excision of excessive skin and subcutaneous tissue (includes lipectomy), arms and 
other areas.
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 needs this care to maximize 
recovery. The Plan denied your request. The Plan says the enrollee's needs can be safely managed at the current 
facility until they are more stable for transfer to another level of care.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current setting, and medical records 
do not support LTACH services at this time.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips. 
 
  You asked the Plan to pre-approve additional trips. You say that you need more rides for physical therapy, in 
conjunction with infusion appointments. You also say that you are not able to get a rental car, do not have the 
resources to get to these important appointments, and the appointments are too far to walk to. The Plan denied 
your request. The Plan says as of October 3, 2023, you have used ten out of the twelve trips allowed with your 
non-emergent transportation benefit for 2023. The Plan also says that although this may be a beneficial service, 
your Evidence of Coverage states that you are allowed twelve one-way trips to Plan-approved locations. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 12 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have, or will have exhausted the Plan maximum benefit for coverage of routine transportation, and this 
request exceeds the limitation. Therefore, we decided that the Plan does not have to pre-approve additional 
trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64999 rendered on November 28, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 64999-62-59-51 is not supported by the medical records submitted. 
 
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 64999 is "Unlisted procedure, nervous system." 
 
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 says that the services at issue in 
this case were not supported by the medical records submitted. Our reviewer found that the procedure report 
does not include sufficient documentation to support an unlisted procedure was performed. When performing a procedure which does not have an assigned procedure code, medical record should include documentation of 
the procedure performed. In this case, this procedure cannot 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 64999 rendered on November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64493, 64494, and G3002 rendered on April 
11, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation submitted does 
not support the codes in question. There is no evidence that injections of the paravertebral facet joint, initial 
and subsequent, were performed with image guidance. The record also does not support that pain management was performed for 30 minutes. The codes in question are not supported by the medical record submitted. 
 
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 64493, 64494, and G3002 rendered on April 11, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy services. You say that you do not feel comfortable 
switching physical therapists when I have already started with this one. The Plan denied your request. The Plan 
says you have requested to receive these services from a non-participating provider. The Plan also says there 
are three participating providers available in your network to provide the same service.  
Medicare rules say that plans can require you to get care from network providers. The contract says the Plan 
will cover services from either network or out-of-network providers, as long as the services are covered 
benefits and are medically necessary. If you use an out-of-network provider, your share of the costs for your 
covered services may be higher. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services rendered by an OON provider at the in-network rate. Therefore, 
we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transplant-related lodging provided from April 13, 2023, to 
May 11, 2023. 
 
You asked the Plan to pay for lodging. You say that you feel that the Plan did not live up to their program by 
not communicating exactly what needed to be done. The Plan denied your request. The Plan says there is no 
transplant authorization on file with the lodging code included as required for reimbursement. 
 
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 lodging have been met. You did not submit supporting documentation to show the transplant authorization with lodging code. You may submit 
supporting documentation to the Plan for reconsideration of your claim. Therefore, we decided that the Plan 
does not have to pay for transplant-related lodging provided from April 13, 2023, to May 11, 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 24, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
prior to your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service April 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81340 billed for date of service April 14, 
2023. 
 
You asked the Plan to pay for procedure code 81340. You say that this service was necessary and is supported 
as billed. The Plan denied your request. The Plan says this code was not billed with a diagnosis code which 
supports medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 81340. Any codes which are not listed are considered not medically necessary for 
code 81340. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 81340 have not been met. Specifically, this claim was submitted with a diagnosis 
code which is not among those codes listed as medically necessary and appropriate for this service. Therefore, we decided that the Plan does not have to pay for procedure code 81340 billed for date of service April 14, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Compressor XL received on April 13, 2023. 
 
You asked the Plan to pay for the Compressor XL. You say that you would like reimbursement for this item. 
The Plan denied your request. The Plan says the item is not covered when received by a provider that does not 
participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the Compressor XL received on April 
13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion (Vertiflex) device (22869). 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the device is medically necessary. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental and investigational. There is more research 
needed due to insufficient evidence of efficacy. 
 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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Superion (Vertiflex) device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (power scooter K0800). 
 
You asked the Plan to pre-approve power scooter. You say that there are very few places you can go because 
you cannot walk very much. The Plan denied your request. The Plan says you exceed the weight capacity of the 
requested power operated vehicle. 
 
The Plan must follow Medicare rules. Medicare rules say that a power operated vehicle may be covered if the 
enrollees weight is less than or equal to the weight capacity of the device.  
 
We looked at the file and Medicare rules. The record shows that your weight is greater than 300 pounds; 
therefore, a K0800 power operated vehicle is not appropriate for you. Based on this information, we decided 
that Medicare rules for coverage of power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power operated vehicle (power scooter K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy. 
 
You asked the Plan to pre-approve Ubrelvy. You say that Ubrelvy is indicated for the acute treatment of 
migraine in adults. You also say that you believe the provided information, along with your medical 
recommendations, will establish the medical necessity for payment of this claim. The Plan denied your request. 
The Plan says the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy.  
 
Benefits for Ubrelvy may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 26, 2022, to August 
24, 2022. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met.  
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 home health services have been met. 
Specifically, recertification documentation for the period of care at issue has not been provided. Therefore, we 
decided that the Plan does not have to pay for home health services provided from July 26, 2022, to August 24, 
2022.
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 needs this care to regain strength for 
daily living. The Plan denied your request. The Plan says medical records do not show that the enrollee 
requires SNF services, and care can safely be provided at a different setting.  
 
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 (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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 3, 2023, billed with 
codes 81227, 81230, 81231, 8232, 81240, 81241, 81291, 81306, 81328, 81335, 81355 and 81479. The Plan 
also does not have to pay for genetic testing provided on February 3, 2023, billed with codes 81225, 81226 and 
81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim and that you have billed with an incorrect place of service 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. Procedure codes 81227, 81230, 81231, 8232, 81240, 81241, 81291, 
81306, 81328, 81335, 81355 and 81479 constitute an NGS panel that was not billed with a single panel code as 
required. 
 
Medicare rules say that, for lab services, the POS code must reflect the location in which the sample was taken. 
POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 81225, 81226 and 81401 have not been met. Specifically, this claim was billed 
with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. 
 
Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 
3, 2023, billed with codes 81227, 81230, 81231, 8232, 81240, 81241, 81291, 81306, 81328, 81335, 81355 and 
81479. The Plan also does not have to pay for genetic testing provided on February 3, 2023, billed with codes 
81225, 81226 and 81401.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA). 
 
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 PTA 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 records show that you have high 
blood pressure and diabetes. You had a positive stress test but there is no documentation that medication to 
lower blood pressure (anti-ischemic) has been used. The guidelines do not support the use of cardiac 
catheterization in this instance. The cardiac catheterization with PTA is therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous transluminal angioplasty (PTA).