Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service August 16, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service August 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA of the SI joint. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this procedure is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA of the SI joint is not considered reasonable 
and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of RFA of the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-
approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that the service should be covered. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, you are not at high risk for an unplanned 
hospitalization. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits 
for the chronically ill (SSBCI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81479). 
 
You asked the Plan to pre-approve the genetic testing. You say that this test is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genetic testing. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the current literature does not support that this test panel leads to significant improvements in 
the overall outcome of the patient compared to standard medication adjustments without testing. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (81479).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc allograft procedure (0627T). 
 
You asked the Plan to pre-approve VIA Disc allograft procedure. You say that the requested procedure is 
necessary for the enrollee. The Plan denied your request. The Plan says the requested procedure is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve VIA Disc allograft procedure. Our 
reviewer says that the requested VIA Disc allograft procedure is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this procedure is considered experimental and 
investigational. Therefore, the reviewer found that this procedure is not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA Disc allograft procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve VIA Disc allograft procedure (0627T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2377, E2313) and a 
power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve the upgraded electronics and power seat elevation feature. You say that the 
requested items are medically necessary. The Plan denied your request. The Plan says that the upgraded 
electronics are not medically necessary. The Plan also says that a power seat elevation feature is not primarily 
medical in nature. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are covered when it is medically 
necessary to control the power options through the joystick. The rules also say that items must serve a medical 
purpose.  
 
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 upgraded electronics and power seat 
elevation feature. Our reviewer says that the coverage criteria has not been met. Our physician reviewer found 
that you do have use of your extremities and can operate and control the power options using the switches that 
are included in the basic wheelchair. 
 
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 upgraded electronics have not been met. The power seat elevation feature is 
not covered as it does not serve a medical purpose. Therefore, we decided that the Plan does not have to pre-
approve upgraded electronics (E2311, E2377, E2313) and a power seat elevation feature (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36247, 36248, 75710, and 75774 billed for 
date of service October 3, 2022. 
 
You asked the Plan to pay for the billed services. You say that the guidelines for filing have been met. The Plan 
denied your request. The Plan says the billed codes 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 75710-XU is angiography, extremity, unilateral, 
radiological supervision and interpretation. The definition of code 75774-XS is angiography, selective, each 
additional vessel studied after basic examination, radiological supervision and interpretation (List separately in 
addition to code for primary procedure). We find that CPT codes 75710 and 75774 are not separately 
reportable when billed with a vascular procedure. The records do not show that the services were performed on 
a separate anatomic site, or that it was an unusual non-overlapping service. The records also do not support 
supervision or an interpretation.  
 
The definition of code 36247 is selective catheter placement, arterial system; initial third order or more 
selective abdominal, pelvic, or lower extremity artery branch, within a vascular family. The definition of code 
36248 is selective catheter placement, arterial system; additional second order, third order, and beyond, 
abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial 
second or third order vessel as appropriate). We find that the catheter placement was an integral part of the 
main procedure. The records do not show that they were separate or distinct services. 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 codes 36247, 36248, 75710, and 75774 billed for 
date of service October 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary, the services you need can be provided safely in 
other settings, for example, a skilled nursing 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT) services 
(G6001). 
 
You asked the Plan to pre-approve IGRT. You say that the requested services are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested services are experimental/investigational. 
 
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 IGRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that usually IGRT is used when critical structures are abutting or in close proximity to the target that is 
being treated to high doses. This situation does not apply to the enrollee, in whose case the target lesion can be 
seen on the skin to assist in daily set up.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT) services (G6001).
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. The Plan denied your request. The Plan says the enrollee's records 
do not show that you do not have complex rehabilitation needs that require frequent evaluation by a 
rehabilitation doctor. Services needed may be provided safely in a lower level of care. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home ventilator, any type, used with non-invasive interface 
(E0466) provided October 24, 2022. 
 
You asked the Plan to pay for a ventilator. You say that that please see the attached medical records supporting 
medical necessity. The Plan denied your request. The Plan says the request is not medically necessary because 
the records show that the requested device is to be used in a bi-level PAP mode (VAPS), which can be 
provided by another device. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has a diagnosis of COPD and was hospitalized with an acute exacerbation in 
September 2022.  Arterial blood gas (ABGs) was consistent with acute on chronic hypercarbic respiratory 
failure. The enrollee improved on BiPAP with average volume assured pressure support (AVAPS) along with 
other treatments.  Progress notes indicate the enrollee has BiPAP at home but does not tolerate it. There are no 
pulmonary function tests to assess the severity of the COPD.  There is no diagnosis of thoracic restrictive 
disease or neuromuscular disease. There is no ABG done while stable to confirm chronic CO2 retention.  If that 
is present, the patient may benefit from BiPAP with AVAPS during sleep as an outpatient.  Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. A home ventilator is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pay for a home ventilator, any type, used with non-invasive interface (E0466) provided October 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01230 billed for date of service October 12, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says an inappropriate 
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 code. 
 The claim at issue was billed with place of service code 22, an outpatient hospital facility. The medical records 
and enrollees claim information shows that the enrollee was an inpatient at the time the services were 
provided. 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 01230 billed for 
date of service October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office consultation with an out-of-network (OON) 
rheumatologist. 
 
You asked the Plan to pre-approve an office consultation with an OON rheumatologist. You say that your 
oncologist referred you to the requested OON provider who works at the same cancer treatment facility where 
you are being treated. You say that it is necessary to see the requested OON provider so that the doctors who 
are treating you can all work together. The Plan denied your request. The Plan says the services needed can 
safely be rendered in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 office consultation with an OON 
rheumatologist. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found you are not currently receiving any active treatment and/or medical management of your 
condition at the OON facility that makes it medically necessary for you to continue care with providers only 
working out of that OON facility. There is not anything unique about your condition that would make it 
medically necessary for you to continue care with the OON facility of providers. The Plan has shown that they 
have in-network specialists who have the qualifications and expertise necessary to meet the current medical 
Standards of Care required for treatment of your condition. Your medical management and/or follow-up care 
can be safely transitioned to an in-network specialist 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 an office consultation with an OON rheumatologist have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an office consultation with an out-of-network 
(OON) rheumatologist.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high intensity-focused ultrasound (HIFU). 
 
You asked the Plan to pre-approve an HIFU. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an HIFU. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found although HIFU is approved by the FDA for destruction of prostate tissue, it is not approved 
explicitly for the treatment of prostate cancer. Use is endorsed for after radiation therapy which this enrollee 
has not had. Per the NCCN Guidelines for those with a life expectancy less than or equal to 10 years, positive biopsy, and no distant metastases, observation or androgen deprivation therapy (ADT) are appropriate options. 
In addition, staging imaging was done 1 year ago. The service is not reasonable or 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 an HIFU have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a high intensity-focused ultrasound (HIFU).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a Barostim Neo system. 
 
You asked the Plan to pre-approve implantation of a Barostim Neo system. 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 implantation of a Barostim Neo system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there remains an absence of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a 
result, at this time the Barostim Neo system would not be considered medically reasonable and necessary in this 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 implantation of a Barostim Neo system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of a Barostim Neo system.