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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the medial branch 
nerves (64636, 64635). 
 
You asked the Plan to pre-approve RFA of the medial branch nerves. 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 follows Medicare rules. Medicare rules say that facet joint injections are 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 RFA of the medial branch nerves. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the LCD criteria is 
80% pain relief for each set of the diagnostic MBBs. This was not achieved and therefore, the request is 
deemed 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 RFA of the medial branch nerves have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation (RFA) of the medial branch nerves (64636, 
64635).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Invitae Lynch Syndrome Panel testing. 
 
You asked the Plan to pre-approve Invitae Lynch Syndrome Panel. You say that this test is medically 
necessary, and the enrollee has a family history of Lynch syndrome. The Plan denied your request. The Plan 
says although the enrollee has a family history of Lynch syndrome, there is no indication that the enrollee has a personal history of Lynch syndrome. Genetic testing is not an appropriate screening and is not covered when 
performed as a screening in an enrollee with no personal history. 
 
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, Invitae Lynch Syndrome Panel, is being 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 pre-approve Invitae Lynch Syndrome Panel testing.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to reimburse an additional amount of $1.01 for the surgical service. We decided 
that the Plan does not have to reimburse any additional amount over the Medicare allowed amount for the 
surgical service.  
 
You asked the Plan to reimburse an additional amount for the insertion of multi-component, inflatable penile 
prosthesis (54405) provided on April 27, 2023. You say that You say that you do not agree with the amount of 
$727.39 that was paid for these services. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reimburse an additional amount of $1.01 for the surgical service.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for Outpatient Surgery in your area.  
 
The Physician Fee Schedule shows that the Medicare allowed amount for this service in your area is $809.33. 
The Evidence of Coverage clearly shows there is a 10% coinsurance for outpatient surgery services received in 
your area. $809.33 x 10% coinsurance = $728.40 Plan payment. The record shows that the Plan only 
reimbursed $727.39. $728.40 - $727.39 = $1.01. Therefore, the Plan is responsible for an additional payment of 
$1.01. Therefore, we decided that the Plan has to reimburse an additional amount of $1.01 for the surgical 
service.  
 
We also decided that the Plan does not have to reimburse any additional amount over the Medicare 
allowed amount for the surgical service. 
 
The record shows that the provider in this case is a Medicare provider. Medicare providers should not charge 
more than the Medicare-allowed amount for services. Therefore, we decided that the Plan does not have to 
reimburse any additional amount over the Medicare allowed amount for the surgical service. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 11, 2023. 
 
You asked the Plan to pay for the lab services. You say that this lab service is a covered benefit. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. 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 the lab services 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. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Kit 3 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre Kit 3 sensor. The Plan denied your request. The Plan 
says the information provided was not sufficient to support approval for medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 FreeStyle Libre Kit 3 sensor have 
been met.  There were no medical records provided. Without this necessary information, we are unable to determine 
whether the criteria for coverage have been met. Specifically, the Plan has shown that they made reasonable 
attempts to obtain this necessary information from the provider. Therefore, we decided that the Plan does not 
have to pre-approve a FreeStyle Libre Kit 3 sensor.
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 needs LTACH level of care 
so that they still have access to ventilator support. 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 enrollee is improving but still is unstable and only requires short-term acute 
care at the current facility until they are more stable. The enrollee does not require services at the LTACH that 
are not already available at the current facility.  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic laboratory testing provided on April 06, 2023. 
 
You asked the Plan to pay for genetic laboratory testing. You say that this was medically necessary for this 
patient. Please not the medical records and approve billing. 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 genetic laboratory 
testing provided on April 06, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on February 13, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that this provider was covered under your previous 
carrier. The Plan denied your request. The Plan says this provider is not part of the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal lumbar puncture to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the OON spinal lumbar puncture. You say that you have been waiting 3-
months for this approval. The Plan denied your request. The Plan says in-network neurology providers are 
available who can provide the services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services with an OON provider. Therefore, we decided that the Plan does not have to 
pre-approve a spinal lumbar puncture to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 7, 2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 7, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre 3 and the supply allowance. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 and the supply allowance. You say that the requested 
CGM is medically necessary for the enrollee. The Plan denied your request. The Plan says that the Freestyle 
Libre 3 is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre 3 and the supply 
allowance. Our reviewer says that the CGM coverage criteria was met. Our physician reviewer found that as 
the enrollee is taking insulin and the enrollee meets criteria for CGM coverage given above. The enrollee has 
glycemic excursions and is therefore is an ideal candidate for the Freestyle Libre 3 CGM which will alert the 
enrollee to low or high blood sugars. 
 
We looked at this physician's review, the file, and Medicare rules. The Freestyle Libre 3 is now a covered 
device, as it has been assigned the covered code of E2103 as of June 15, 2023. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Libre 3 and the supply allowance have been met. 
Therefore, we decided that the Plan has to pre-approve a Freestyle Libre 3 and the supply allowance.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 02, 2023. 
 
You asked the Plan to pay for lab services. You say that the referring provider is in-network. 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 lab services provided on 
May 02, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve self-administered drugs provided on March 7, 2023. 
 
You asked the Plan to pre-approve the medication. You say that you were given a Morphine pill that was 
administered by the staff, it was not self-administered. 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 self-administered drugs 
provided on March 7, 2023.  
 
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that you should not have to wait till you are a diabetic to 
receive the benefits of a CGM. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not have diabetes. Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the LTACH 
admission. 
 
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 appears to currently not yet be stable for transfer and requires additional 
short-term acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer.  The enrollee does not require services at the LTACH that are not already available at the current facility. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a NALU peripheral nerve stimulator (64555). 
 
You asked the Plan to pre-approve a NALU peripheral nerve stimulator. 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 a NALU peripheral nerve stimulator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this procedure would be considered experimental for this 
condition. Therefore, the request is deemed 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 a NALU peripheral nerve stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a NALU peripheral nerve stimulator (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services (procedure code 64450) rendered on May 
1, 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. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that 
modifier -59 was appended to CPT 64448 to indicate that the service is a distinct procedural service provided 
by the anesthesiologist for postoperative pain management. In addition, CPT 64550-59 was billed, which represents an anesthetic agent and/or steroid, other peripheral nerve or branch. The records indicate that an 
IPACK block was performed. The more appropriate CPT code 64999 should be used to billed for the service 
provided (not 64450-59). The medical records submitted do not support the billing of CPT 64450-59-LT. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services (procedure code 64450) rendered on May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve radiofrequency ablation (RFA) 
(64624). 
 
You asked the Plan to pre-approve a genicular nerve RFA. 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 a genicular nerve RFA. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental therapy. It is the subject of ongoing clinical 
trials. Therefore, the request is deemed 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 a genicular nerve RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve radiofrequency ablation (RFA) (64624).