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

 
We decided that the Plan does not have to pre-approve an additional 4 routine transportation trips. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that the services are medically 
necessary. The Plan denied your request. The Plan says you have exceeded your yearly benefit limit. 
 
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 30 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 4 routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 7, 2023, billed with 
codes 87481 and 87798 x13. 
 
You asked the Plan to pay for the genetic testing billed. You say that all services rendered were properly 
ordered and signed by the treating provider and deemed medically necessary for this enrollee per diagnosis of 
treatment. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. The panel tested for over 50 pathogens. The PCR panel testing is considered excessive testing and 
not medically necessary. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on June 7, 2023, billed with codes 87481 and 87798 x13.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx (81551) provided April 17, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial of ConfirmMDx 
for prostate cancer.  The Plan denied your request. The Plan says this service did not meet the Medicare 
medically necessary criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The enrollees prostate biopsy was also performed on April 17, 
2023. Per NCCN guidelines, ConfirmMDx is not recommended to be done at the same time as the biopsy and 
not without evidence that another biopsy is warranted. Per CMS guidelines LCD L39005, the ConfirmMDx test 
was ordered prematurely, shortly after (same day) as the biopsy and well as before there would be sufficient 
time to detect digital rectal exam (DRE) changes or increasing prostate specific antigen (PSA) that would 
warrant a decision for a repeat biopsy. Based on this information, we decided that Medicare rules for coverage 
of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for 
ConfirmMDx (81551) provided April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81433 billed for date of service May 25, 
2023. 
 
You asked the Plan to pay for procedure code 81433. You say that the enrollee's physician ordered genetic 
testing due to its validated clinical utility in clarifying disease risk The Plan denied your request. The Plan says 
procedure code 81433 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 81433 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 81433 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 81433 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 81433 billed for date of service May 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NuVasive Osteocel allograft (20930). 
 
You asked the Plan to pre-approve NuVasive Osteocel allograft. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of NuVasive 
Osteocel allograft in the setting of cervical stenosis and radiculopathy, have not been demonstrated in the peer-
reviewed literature. 
 
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 NuVasive Osteocel allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that osteocel allograft is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NuVasive Osteocel allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve NuVasive Osteocel allograft (20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Osteoflo (SurGenTec) (20930). 
 
You asked the Plan to pre-approve Osteoflo . You say that non-operative treatments have failed. The Plan 
denied your request. The Plan says Osteoflo allograft remains experimental in spine surgery and more research 
is needed. 
 
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 Osteoflo . Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that Osteoflo allograft is experimental. More research is needed.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Osteoflo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Osteoflo (SurGenTec) (20930).
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 if you are discharged home, the level of 
oxygen you require is too much for the home oxygen system to handle and you will be readmitted to the 
hospital. The Plan denied your request. The Plan says the level of care provided in an LTACH setting is more 
than your medical conditions need.  
 
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 you are receiving appropriate care in the current acute care setting as provided by 
the Plan. The documentation does not support that LTACH services are medically appropriate at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical gel (J7345) and photodynamic therapy (96573) 
provided on April 1, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that you have repeatedly tried to get this claim 
paid. The Plan denied your request. The Plan says the claim was not filed timely. 
 
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 outpatient service was not filed until April 12, 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 topical gel (J7345) and photodynamic therapy (96573) 
provided on April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma injections for non-wound injections. 
 
You asked the Plan to pre-approve platelet rich plasma injections for non-wound injections. You say that you 
need these injections because you are unable to walk and perform daily activities due to the amount of pain you 
are in. The Plan denied your request. The Plan says it is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this is a non-coverage policy for all Platelet Rich 
Plasma injections and/or applications as a means of managing musculoskeletal injuries and/or joint 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 platelet rich plasma injections for non-
wound injections. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
the use of platelet-rich plasma (i.e. autologous blood-derived preparations) is considered experimental or 
investigational for the treatment of acute or chronic wounds, including surgical wounds, and non-healing 
ulcers. The evidence is insufficient to determine the effects of the technology on health outcomes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of platelet rich plasma injections for non-wound injections have not been met. 
Therefore, we decided that the Plan does not have to pre-approve platelet rich plasma injections for non-wound 
injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high frequency chest wall oscillation devices. 
 
You asked the Plan to pre-approve high frequency chest wall oscillation devices. You say that it is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval. 
 
The Plan follows Medicare rules. Medicare rules say that there must be well-documented failure of standard 
treatments to adequately mobilize retained secretions. 
 
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 high frequency chest wall oscillation 
devices. Our reviewer says that the service is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has alpha-1 antitrypsin deficiency and chronic obstructive pulmonary disease without 
documentation of bronchiectasis.  The record provided does not document the presence of an enumerated 
condition for which coverage is available under the rules. The elements of the coverage criteria are not 
satisfied.  The requested service is not recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of high frequency chest wall oscillation devices have not been met. Therefore, we 
decided that the Plan does not have to pre-approve high frequency chest wall oscillation devices.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service May 11, 
2023.  
 You asked the Plan to pay for procedure code 76641. You say that the claim was billed with the same code and 
different modifiers. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service May 11, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration based on medical 
necessity. The Plan denied your request. The Plan says the IRF services requested do not meet the requirements 
for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall complies with the various documentation requirements for an IRF admission 
as best summarized by the physical therapy note on October 16, 2023 and the occupational therapy note on 
October 17, 2023. Your condition is in fact sufficiently complex, and there is every reason to expect that you 
will participate in and benefit from services to include at minimum physical and occupational therapy, 
physician oversight of polypharmacy and case manager coordination of any additional services that might be 
needed to make a sustainable return home, as well as avoid preventable readmissions to the acute hospital. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 urine polymerase chain reaction (PCR) panel testing 
(87841, 87798, 87801), provided on May 16, 2023. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that the service was medically necessary. 
The Plan denied your request. The Plan says this service was 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 pay for the urine PCR panel testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is not the standard of care for the enrollee's diagnosis. 
 
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 urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing (87841, 87798, 87801), 
provided on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 billed for date of service March 29, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the records illustrate the need for services. The 
Plan denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99309 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. 
 
We find that CPT code 99309 is not supported. The claim shows that code 99309 was billed with assisted 
living place of service code 13. The billed procedure code is inconsistent with the place of service code billed. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99309 billed for date of 
service March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the outpatient service. You say that this clinic is the easiest for you to get to. 
You say that you do not drive. You also say that this clinic is on your bus route. The Plan denied your request. 
The Plan says there are network providers available. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor.  
You asked the Plan to pre-approve a Freestyle Libre 2 continuous glucose monitor. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested device is not medically 
necessary. 
 
The Plan follows 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 2 continuous glucose 
monitor. Our reviewer says that the documentation does not support that the requested device is medically 
reasonable or necessary. Our physician reviewer found the enrollee has been treated with trulicity and now 
ozempic as well as metformin. The documentation shows that the enrollee is not on medications that usually 
cause low blood glucose sugars. The enrollee is not on insulin. The documentation does not support why 
fingerstick meter would not suffice for the enrollee at this time. Therefore, the enrollee does not meet criteria 
for the requested 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 a Freestyle Libre 2 continuous glucose monitor have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor.
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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested 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 presently receiving appropriate services in the acute care setting. 
The records do not support the need to transfer from one acute hospital to another. Continued care in the short-
term acute hospital is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair and accessories. 
 
You asked the Plan to pay for the wheelchair and accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says this item is not covered when used in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair and accessories was used in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pay for the wheelchair and accessories.