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

 
We decided that the Plan does not have to pay for radiological services provided on October 5, 2022. 
 You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says payment for the billed code is included in payment 
for code 36581. 
 
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 36595-52-XU is a column II code to column I code 36581; however, 
36595-52-XU was billed with a modifier.  
 
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 radiology services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the modifiers used are not supported in 
this case, as replacement of venous catheter was performed as well as an intervention in same anatomical area. 
This procedure would be included in CPT 36581. 
 
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 radiology services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for radiological services provided on October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the goal is to reduce heart failure 
hospitalizations. The Plan denied your request. The Plan says the device is considered unproven. 
 
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 requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure. Published expert opinion in the 
cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollees 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
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 requires services that cannot be provided 
in a sub-acute rehab. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an inpatient rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is walking at a community level. Intensive rehabilitation services are not 
medically necessary per chapter 1. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service December 
27, 2022. 
 
You asked the Plan to pay for procedure code 76140. You say that you believe the billed code is correct. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service December 27, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says that the requested epidural steroid injection 
does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is considered medically necessary in this case. Our 
physician reviewer found that the enrollee has chronic low back pain. The enrollee has had trigger point 
injections and has had medication trials of Tylenol, Flexeril, Gabapentin, Hydrocodone and Oxycodone. The 
enrollee has had RFA of the lumbar spine in the past. The enrollee is doing a home exercise program. Of note 
is that the enrollee is having difficulty emptying her bladder. Imaging shows a compression fracture at L2 and 
foraminal stenosis at L2-L3. The enrollees pain corresponds to the L2 dermatome. The request is for an L2-L3 
epidural steroid injection. The request meets all of the Medicare LCD criteria and is 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 an epidural steroid injection have been met. Therefore, we decided that the Plan 
has to pre-approve an epidural steroid injection.  
 
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: Favorable

 
We decided that the Plan has to pay for physician's services for an office or other outpatient visit provided on 
December 16, 2021. 
 
You asked the Plan to pay for the physician's services for an office or other outpatient visit. You say that no 
other services were rendered by the multispecialty group on this date of service. The Plan denied your request. 
The Plan says that the Plan was previously billed by and paid another provider for this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided documentation showing that the Plan was 
billed by and paid another provider for this service. Therefore, we decided that the Plan has to pay for 
physician's services for an office or other outpatient visit provided on December 16, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A6446, A6021, A6252 and A4450 for date of service 
November 16, 2022.  
You asked the Plan to pay for codes A6446, A6021, A6252 and A4450. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that codes A6446, A6021, A6252 and A4450 are not supported in the medical record. Specifically, 
these items were billed with place of service 32 (nursing facility). Place of service 32 should be billed with 
services for a noncovered stay. This means this place of service is not appropriately billed. The claim is not 
payable as billed. Based on this information, we decided that Medicare rules for coverage of codes A6446, 
A6021, A6252 and A4450 have not been met. Therefore, we decided that the Plan does not have to pay for 
codes A6446, A6021, A6252 and A4450 for date of service November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro orthotic device. 
 
You asked the Plan to pre-approve MyoPro orthotic device. 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 MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrolle's stroke was over 2 years ago. the response to myoeletric orthosis is 
unpredictable at best and has low likelihood of having impact on activity of daily living (ADL) status when 
deployed more than one year post stroke. Contractures impede function of the orthosis, and it is unclear what degree of contracture the enrollee has. His impairment in function is not provided so cannot be determined how 
much impact on ADL status is needed. The American Heart Association has noted the orthosis may add to 
standard therapy but is silent on the arm as a reasonable means of improving function once therapy is 
completed. The device is not standard of care and has been shown to reliably improve ADL function when 
compared with usual care, especially when deployed more than 2 years post stroke. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro orthotic device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MyoPro orthotic device.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for PancraGEN testing (81479) provided on December 30, 2022. 
 
You asked the Plan to pay for PancraGEN testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that this test is missing a 
necessary DEX Z-code for reporting. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the rules used by the Plan to deny this test do not apply to the state 
where these services were actually performed. We were unable to find this same rule in a determination with 
jurisdiction over the state at issue. Therefore, the Plan's denial is not substantiated in this case. Therefore, we 
decided that the Plan has to pay for PancraGEN testing (81479) provided on December 30, 2022.  
 
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 the Tempus gene panel testing (81455) provided on June 16, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that denial of this claim based on failure to obtain 
prior authorization is not justifiable in this instance. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the Tempus gene panel testing (81455) provided 
on June 16, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zoloft. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee needs this medication. 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 Zoloft.   
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: 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 the services are not medically necessary. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies. IRF criteria not met. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy. 
 
You asked the Plan to pre-approve HBO therapy. 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 program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions 
 
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 HBO therapy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation as to the 
level of glycemic control, and the response to standard wound care measures or has a Wagner grade III or 
higher ulcer. The review has determined that the enrollee does not meet the coverage criteria detailed in the 
NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuing intrathecal pump delivery of 
Hydromorphone, Clonidine, and an unspecified drug. 
 
You asked the Plan to pre-approve the continuing intrathecal pump delivery of Hydromorphone, Clonidine, and 
an unspecified drug. You say that the continuing intrathecal pump delivery of Hydromorphone, Clonidine, and 
an unspecified drug is medically necessary. The Plan denied your request. The Plan says the continuing 
intrathecal pump delivery of Hydromorphone, Clonidine, and an unspecified drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the continuing intrathecal pump 
delivery of Hydromorphone, Clonidine, and an unspecified drug. Our reviewer says that the continuing 
intrathecal pump delivery of Hydromorphone, Clonidine, and an unspecified drug is not medically necessary. 
Our physician reviewer found neuraxial analgesia is achieved by epidural or intrathecal (IT) administration of 
an opioid alone or in combination with another agent, such as bupivacaine, clonidine, baclofen, or Ziconitide 
(Prialt). When neuraxial analgesia is used, pain relief is obtained in a highly selective fashion, without motor 
and sympathetic blockade, so these modalities are highly adaptable to the home care environment. The medical literature does not support the concurrent use of opioids and benzodiazepines (patient is on Ativan) due to 
dependency and the increased risk of adverse effects, including marked sedation, overdose, and death. The 
community standard and/or recommendation is maximizing conservative therapies prior to an intrathecal (IT) 
pump implant which provides at least 50% relief, and the pump to deliver Food and Drug Administration 
(FDA)-approved intrathecal (IT) pump medications. Minimizing/eliminating opioids when a patient is on a 
benzodiazepine is also a community standard/recommendation. 
 
The review has determined that the documentation does not support that the Hydromorphone, Clonidine, and 
an unspecified drug are medically reasonable or necessary for the enrollee. 
 
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 continuing intrathecal pump delivery of Hydromorphone, Clonidine, and an 
unspecified drug have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuing intrathecal pump delivery of Hydromorphone, Clonidine, and an unspecified drug.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye examination and evaluation (92014) 
provided on October 18, 2022. 
 
You asked the Plan to pay for the vision service. You say that your insurance covers out-of-network providers. 
The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also 
says that payment cannot be made to a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Though the Plan offers a supplemental vision care benefit,  Therefore, 
we decided that the Plan does not have to pay for the medical eye examination and evaluation (92014) provided 
on October 18, 2022.