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

 
We decided that the Plan does not have to pay for a respiratory panel provided on February 15, 2023, and billed 
with codes 87486, 87541, 87631, 87651, and 87798. 
 
You asked the Plan to pay for a respiratory panel. You say that this testing was medically necessary.  The Plan 
denied your request. The Plan says this test should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of a respiratory panel have not been met. 
Therefore, we decided that the Plan does not have to pay for a respiratory panel provided on February 15, 2023, 
and billed with codes 87486, 87541, 87631, 87651, and 87798.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omage3 skin substitute (Q4158). 
 
You asked the Plan to pre-approve the service. You say that the requested Kerecis Omage3 skin substitute is 
medically necessary. The Plan denied your request. The Plan says the requested Kerecis Omage3 skin 
substitute 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficiency scientific evidence for Kerecis Omega3 skin substitute to be 
recommended as standard of care, and the enrollee does not meet criteria as outlined. This is 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Kerecis Omage3 skin substitute (Q4158).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wireless capsule endoscopy provided on 
November 18, 2022. 
 
You asked the Plan to pay for the wireless capsule endoscopy. You say that the wireless capsule endoscopy 
was medically necessary. The Plan denied your request. The Plan says according to the report, the capsule did 
not advance past the esophagus. There is no documentation of iron-deficiency anemia, stool studies, or 
previous endoscopy/colonoscopy.  
 
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 wireless capsule endoscopy. Our 
reviewer says that the requested wireless capsule endoscopy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the documentation does not adequately support that a 
capsule endoscopy was necessary (e.g,. iron deficiency anemia with negative EGD and colonoscopy). 
 
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 wireless capsule endoscopy have not been met. Therefore, we decided that 
the Plan does not have to pay for a wireless capsule endoscopy provided on November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 19083 provided on October 5, 2022. 
 
You asked the Plan to pay for procedure code 19083. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 19083 is not supported. This code has a bilateral surgery indicator of 1. This means the 
code should be reported with 1 unit of service and modifier 50 (bilateral modifier) or an appropriate anatomical 
modifier (right or left) to be considered for payment. Based on this information, we decided that Medicare rules 
for coverage of code 19083 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 19083 provided on October 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 18, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says a sacroiliac joint 
injection 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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the LCD criteria requires 50% 
pain relief for 3 months. The requirements have not been achieved and therefore the request is not medically 
reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of carotid sinus Baroflex activation device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says clinical studies have not definitively established that this device is more effective than 
established alternatives. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable and necessary 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve implantation of carotid sinus Baroflex activation device.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 60-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
chemotherapy appointments. The Plan denied your request. The Plan says you have exhausted your 
transportation benefit. 
 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 60 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 exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
60-trip limit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Assay testing (81455) provided on March 15, 
2023. 
 
You asked the Plan to pay for the Tempus xT Assay testing. You say that this testing was medically necessary 
and reasonable for this enrollee. The Plan denied your request. The Plan says the records do not show that the 
enrollee has recurrent, relapsed, resistant (refractory), cancer that has spread from original site to another part 
of the body (metastatic), or advanced stages III or IV cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS panels may be covered when the enrollee 
has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus xT Assay testing have not been met. Specifically, the documentation does not support 
that the enrollee has recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Therefore, 
we decided that the Plan does not have to pay for the Tempus xT Assay testing (81455) provided on March 15, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Synvisc One (J7325). 
 
You asked the Plan to pre-approve Synvisc One. You say that Synvisc One is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says Synvisc One 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 Synvisc One. Our reviewer says that the 
requested drug is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that the provided records in this case do not document that the clinical diagnosis is supported by radiologic 
evidence of osteoarthritis of the knee, such as joint space narrowing, subchondral sclerosis, osteophytes and 
sub-chondral cysts. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Synvisc One (J7325).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as U0004, 99001 and U0005 
provided August 9, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you request review and payment of the 
claim. The Plan denied your request. The Plan says the claim was received past the timely filing limitation. 
 
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 laboratory service was not filed until March 2, 2023. 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 the laboratory services coded as U0004, 99001 and U0005 
provided August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EBT with surface application. 
 
You asked the Plan to pre-approve EBT. You say that this therapy is medically necessary. The Plan denied 
your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve EBT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no evidence showing EBT is the best option for the enrollee. There is still limited 
data regarding the risks versus the benefits, efficacy, and safety of EBT in the treatment of early-stage non-
melanoma skin cancers. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of EBT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve EBT with surface application.
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 is able to progress with intense therapy 
services. The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous 
basivertebral nerve ablation at L3-S1 levels, in this case, 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed with diagnosis codes R56.9 and 
G40.909 provided on March 17, 2023. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes R56.9 and G40.909 should not be reported together. Therefore, we decided that the Plan does 
not have to pay for procedure code 70450 billed with diagnosis codes R56.9 and G40.909 provided on March 
17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spine x-ray provided on April 20, 2023. 
 
You asked the Plan to pay for the spine x-ray. You say that you are requesting reconsideration for the denied 
claim. 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 spine x-ray provided 
on April 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided October 27, 2022 to 
November 8, 2022. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 27, 2022. The NOA was not received by the Plan until April 20, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
October 27, 2022 to November 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) unit 
monthly supplies code as A4556, A4557 and A4630 provided September 10, 2022. 
 You asked the Plan to pay for the TENS unit supplies. You say that please review the attached documents and 
reprocess the claim. The Plan denied your request. The Plan says the documentation requirements have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Also, the records show that the enrollees chief complaint was 
chronic low back pain. Per Medicare rules, TENS therapy for chronic low back pain will be denied as not 
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of for a 
TENS device have not been met. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (TENS) unit monthly supplies code as A4556, A4557 and A4630 
provided September 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service coded as U0004 and U0005 provided 
March 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the claim was received after the timely 
filing limitation. 
 
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 laboratory services was not filed until March 30, 2023. 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 the laboratory service coded as U0004 and U0005 provided 
March 29, 2021.