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

 
We decided that the Plan does not have to pay for SNF care provided from April 29, 2023, to May 28, 2023.  You asked the Plan to pay for SNF care. You say that the services the enrollee received during the period in 
question are coverable. The Plan denied your request. The Plan says the enrollee did not require daily skilled 
services. 
 
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 pay for 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 did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. The 
enrollee's care needs could have been provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from April 29, 2023, to May 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing, 22 or more drug classes (G0483) 
provided on May 2, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that you request reconsideration and payment in 
full for the toxicology drug screen performed f the enrollee. 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 definitive drug testing, 22 or more drug classes 
(G0483) provided on May 2, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) assessment using the 
ImpediMed L-Dex testing device. 
 
You asked the Plan to pre-approve the ImpediMed L-Dex testing device. You say that the enrollee underwent 
adjuvent chemotherapy. You say that the enrollee is at high risk of developing lymphedema as a result. You 
also say that use of ImpediMed L-Dex testing device is medically necessary. The Plan denied your request. The 
Plan says this is considered experimental and therefore is not covered. 
 
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 ImpediMed L-Dex testing device. 
Our reviewer says that the requested ImpediMed L-Dex testing device is not considered medically reasonable 
and necessary in this case. Our physician reviewer found current literature does not sufficiently support the use of this device for this specific clinical situation. There is insufficient high-quality evidence to show use of this 
device leads to significantly improved outcomes compared to standard screening methods. Also, the provided 
documentation does not show the patient having extensive axillary surgery, radiation, or infection to show an 
increased risk of lymphedema. Therefore, this request for ImpediMed L-Dex testing will be considered 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 ImpediMed L-Dex testing device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) assessment using the ImpediMed 
L-Dex testing device.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for in-office medical nutrition therapy provided to the enrollee on January 
30, 2023. 
 
You asked the Plan to pay for medical nutrition therapy. You say that this is a covered service and diagnosis. 
The Plan denied your request. The Plan says that the enrollee has a health maintenance organization (HMO) 
Plan and needs authorization to receive services out-of-network. 
 
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. The Plan's denial reason is invalid, as the enrollee has a preferred provider 
organization (PPO) Plan and meets the requirements to receive medical nutrition therapy out-of-network. The 
enrollees contract with the Plan does not state that prior authorization is required to receive this service from 
an out-of-network provider. The Plan did not provide any other rationale or evidence to support a denial of 
payment. Therefore, we decided that the Plan has to pay for in-office medical nutrition therapy provided to the 
enrollee on January 30, 2023.  
 
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 (87150, 87481, 87798, 87801) provided on May 
24, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service. A panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (87150, 87481, 87798, 87801) provided on May 
24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14-day sensor.  
You asked the Plan to pre-approve a FreeStyle Libre 14-day sensor. The Plan denied your request. The Plan 
says as the enrollee is not on insulin and does not have documentation of problematic hypoglycemia, a 
continuous glucose monitor is not covered under current Medicare criteria. 
 
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 the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a FreeStyle Libre 14-day sensor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a FreeStyle Libre 14-day sensor.
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code G0480. We decided that the Plan does not have to pay 
for procedure code 71045.  
 
You asked the Plan to pay for procedure codes G0480 and 71045 billed for date of service June 4, 2023. You 
say that the testing was medically necessary. The Plan says that the diagnosis code is not eligible for coverage. 
 
We decided that the Plan has to pay for procedure code G0480.  
 
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. 
 
We looked at the file and the rules. The Local Coverage Article, A55001, does include diagnosis codes that 
support medical necessity. However, the rules do not explicitly cite diagnosis codes that are excluded from 
coverage. The Plan offered no other rationale for their denial. The Plan has not made reasonable and diligent 
efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we 
decided that the Plan has to pay for procedure code G0480 billed for date of service June 4, 2023.  
 
We also decided that the Plan does not have to pay for procedure code 71045. 
 
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 diagnosis code Z98.890 was billed on the claim at issue. This diagnosis code is among those 
which are not covered for this testing. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
71045 billed for date of service June 4, 2023.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve placement of an implanted loop recorder (ILR). 
 
You asked the Plan to pre-approve the requested ILR procedure. You say that the enrollee has atrial fibrillation 
and a history of cerebrovascular accident (CVA). You say that the enrollee is on Aspirin and Plavix. You also 
say that this is standard practice of care to work up to a cryptogenic stroke. The Plan denied your request. The 
Plan says that the records do not show that the enrollee had a cryptogenic stroke, or that the Holter monitor 
results were unrevealing or indeterminate. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 ILR procedure. Our 
reviewer says that the requested ILR procedure is found to be medically reasonable and necessary based on 
NCD criteria. Our physician reviewer found the provided documentation indicates that the enrollee has a recent 
history of cryptogenic cerebral vascular accident (CVA), and inconclusive 30 days noninvasive heart 
monitoring. Therefore, the reviewer found that the requested ILR procedure 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 the requested ILR procedure have been met. Therefore, we decided that the Plan 
has to pre-approve placement of an implanted loop recorder (ILR).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insulin lispro. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee uses insulin lispro with an 
Omnipod insulin pump, and it should be covered under Part B. 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 insulin lispro.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for hospital discharge day management (99239) provided on July 3, 2023. 
 
You asked the Plan to pay for hospital discharge day management (99239). You say that the documentation 
shows the time spent was greater than 30 minutes, which supports the CPT code billed for this date of service. 
The Plan denied your request. The Plan says that the medical records submitted do not support hospital 
discharge day management of more than 30 minutes was performed. 
 
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 99239 is hospital inpatient or observation discharge day management; more than 30 minutes on the date 
of the encounter. 
 
We find that CPT code 99239 is supported in the medical record. Specifically, the code definition is time-
based, and the records submitted for review document the total time spent providing the service was greater 
than 30 minutes as required by the code billed. Based on this information, we decided that Medicare rules for 
coverage of hospital discharge day management (99239) have been met. Therefore, we decided that the Plan 
has to pay for hospital discharge day management (99239) provided on July 3, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64616 and J0585 rendered on June 12, 
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 denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 64616: 
 
Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical 
dystonia, spasmodic torticollis)  
Healthcare Common Procedure Coding System (HCPCS) J0585: 
 
Injection, onabotulinumtoxina, 1 unit 
 
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 does not 
support the use of 64616 and J0585. There is no procedure note to support the procedure being performed. 
 
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 64616 and J0585 rendered on June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro 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 experimental and investigational devices are not covered. 
 
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 the current clinical guidelines for adult stroke rehabilitation and recovery designate robotic therapy 
to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with 
unproven benefit in the home environment. In addition, provided records report the patient is on Baclofen 10 
mg three times a day; upper extremity spasticity may be a contraindication to use of the device.  
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 the MyoPro device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve RFA. 
 
You asked the Plan to pre-approve genicular nerve RFA. You say that you need the injection for knee pain. 
You say the tissue at the end of the bone are worn down and causing trouble with walking. The Plan denied 
your request. The Plan says the requested genicular nerve RFA is experimental. 
 
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 genicular nerve RFA. Our reviewer 
says that the requested genicular nerve RFA is not considered medically reasonable and necessary. Our 
physician reviewer found genicular nerve RFA is considered experimental therapy and 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 genicular nerve RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve RFA.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks and RFA.  
 
You asked the Plan to pre-approve the nerve blocks and RFA. You say that you are in tremendous pain and 
require these procedures.  The Plan denied your request. The Plan says experimental and investigational 
procedures are not covered. 
 
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 nerve blocks and RFA. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee pain. 
 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 nerve blocks and RFA have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular nerve blocks and RFA.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (96366, 96368) provided on May 12, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes and 
units are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 96366 is "Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary 
procedure)". The CPT Code Manual definition of code 96368 is "Intravenous infusion, for therapy, 
prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code 
for primary procedure)". 
 
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 units for code 96366 
and the use of code 96368 are not supported by the records provided. Our reviewer found that 4 units of code 
96366 are not supported. There are no start and stop times documented, which is the proper way to document 
an infusion. Going by the time documented, 2.5 hours, 4 additional hours of infusion are not supported. For 
code 96368, the record contains an infusion for one substance; there is no evidence that a second concurrent 
infusion was performed at the same time. 
 
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 the services (96366, 96368) provided on May 12, 2023.