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

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service June 15, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the frequency of services is supported. The Plan 
denied your request. The Plan says the billed code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. There are insufficient medical records to support the billed code. The 
file does show that the Plan made several attempts to obtain medical records with no success. 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 88342 billed for date of service June 15, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bevacizumab. 
 
You asked the Plan to pre-approve bevacizumab. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the use of bevacizumab in combination with olaparib for 
hepatocellular carcinoma is not FDA-approved or listed in the Medicare approved sources.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 bevacizumab. Our reviewer says that 
the requested drug is not medically necessary. Our physician reviewer found that the enrollee has progressed on 
prior bevacizumab and there is no data for the combination with olaparib in hepatocellular carcinoma. The use of the requested drug in combination with olaparib is not supported by one of the major drug compendia or by 
clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bevacizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bevacizumab.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that this is medically necessary. The 
Plan denied your request. The Plan says the documentation does not show the enrollee has syncope and/or 
cryptogenic stroke. 
 
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 not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found while the patient has a history of ventricular tachycardia, there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ILR. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided July 7, 
2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that kindly find the attached 
documents for review which proves the medical necessity for the billed services and process your claim for 
payment. The Plan denied your request. The Plan says a PCD coded as E0675 is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided July 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous imaged-guided lumbar decompression 
(PILD) procedure (0275T). 
 
You asked the Plan to pre-approve a PILD procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is not currently enrolled in trial. 
 
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 PILD procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the PILD procedure 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 PILD procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a percutaneous imaged-guided lumbar decompression (PILD) procedure (0275T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and the progressive lenses provided on August 16, 
2023. 
 
You asked the Plan to pay for the frames and the progressive lenses. You say that you paid out-of-pocket for 
the glasses. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan is limited to one routine eye exam (eye refraction) each year. 
 
We looked at the file and the Plan's rules. Specifically, the eyewear is not a covered benefit Based on this 
information, we decided that the Plan's rules for coverage of the frames and the progressive lenses have not 
been met. Therefore, we decided that the Plan does not have to pay for the frames and the progressive lenses 
provided on August 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from December 11, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from December 11, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
December 11, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of December 11, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond December 11, 
2023, as he was not a danger to himself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of 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 inpatient psychiatric care from December 11, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 11, 
2023, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (33289) and right heart catheterization (93451). 
 
You asked the Plan to pre-approve CardioMEMS and right heart catheterization. You say that this is medically 
necessary. The Plan denied your request. The Plan says this 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 CardioMEMS and right heart 
catheterization. Our reviewer says that there remains a dearth of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of CardioMEMS in patient management.  Our 
physician reviewer found at this time, the CardioMEMS system would not be considered medically appropriate 
and necessary in this enrollees clinical management. Accordingly, the requested right heart catheterization 
performed at time of CardioMEMS placement would likewise not be considered 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 CardioMEMS and right heart catheterization have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (33289) and right heart catheterization (93451).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on May 
8, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on May 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (33289, C2624) 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 CardioMEMS. Our reviewer says that 
there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. Our physician reviewer found 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor (33289, C2624)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 30, 2023, billed with 
codes 81231, 81232, 81306, and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. 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. 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 
April 30, 2023, billed with codes 81231, 81232, 81306, and 81335.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery 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 a bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental when used as bone graft material in 
spine surgery. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with accessories including an 
oxygen tent (E0455, E1028, K0861, E2300). 
 
You asked the Plan to pre-approve the power wheelchair with accessories including an oxygen tent. You say 
that these items were medically necessary. The Plan denied your request. The Plan says coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
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 power wheelchair with accessories 
including an oxygen tent. Our reviewer says that the requested power wheelchair and accessories are not 
medically necessary. Our physician reviewer found the documentation available for review does not include a 
face-to-face assessment with a medical provider, a physician order or an assessment that indicates the 
equipment will be safe for use in the home. 
 
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 power wheelchair with accessories including an oxygen tent have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair with accessories 
including an oxygen tent (E0455, E1028, K0861, E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a T12 kyphoplasty. 
 
You asked the Plan to pre-approve the kyphoplasty. You say that the enrollee had updated magnetic resonance 
imaging (MRI) which showed a burst fracture at T12 with persistent marrow edema which suggests a subacute 
component. You also say that surgical intervention consisting of kyphoplasty is necessary to enhance the 
enrollee's quality of life. The Plan denied your request. The Plan says the onset of the enrollee's symptoms is 
January 2023, more than 12 weeks. 
 
The Plan must follow Medicare rules. Medicare rules say that both PVP and PVA will be considered 
reasonable and necessary when acute or subacute osteoporotic VCF is present, based on symptom onset, and 
documented by advanced imaging demonstrating bone marrow edema on MRI or bone-scan/SPECT/CT 
uptake.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the kyphoplasty have not been met. The record indicates that the enrollee has been experiencing 
pain since they fell in January 2023. More than 12 weeks have elapsed since that time. Therefore, we decided 
that the Plan does not have to pre-approve a T12 kyphoplasty.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart 
(quantitative calcium scoring) (75571) 
 
You asked the Plan to pre-approve a quantitative calcium scoring. You say that you ordered a CT calcium score 
for your patient due to their personal history of hyperlipidemia. The Plan denied your request. The Plan says 
quantitative calcium scoring is not a covered service. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a quantitative calcium scoring, is a screening service. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve a 
computed tomography (CT) scan of the heart (quantitative calcium scoring) (75571)
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 00790 and 99100 provided on February 21, 
2023. 
 
You asked the Plan to pay for procedure codes 00790 and 99100. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules also say that providers must report services with the appropriate 
procedure code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure codes 00790 and 99100 
have been met. In this case, there were no medical records (i.e., anesthesia report, procedure report) provided 
for review to determine if the services were billed correctly. Additionally, we find that procedure code 99100 
has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for procedure codes 00790 and 
99100 provided on February 21, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the physical therapy (97535, 97140, 97110) visit 
provided on July 13, 2023. You asked the Plan to pay more for the physical therapy visit (97535, 97140, 97110). You say that you are 
asking for in-network (INN) reimbursement with INN copayment because you were told at enrollment that 
each individual did not need to enroll. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 50% coinsurance for out-of-network Medicare-covered physical therapy in-person visits.  
 
The enrollee has been asked to pay a $43.15 for the physical therapy (97535, 97140, 97110). The total amount 
allowed to be billed for OON physical therapy provided on July 13, 2023, was $86.30. You have been asked to 
pay an $43.15 coinsurance for these services, which is 50% of the total allowed amount. This item/service falls 
within the outpatient rehabilitation services benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to pay 
more for the physical therapy (97535, 97140, 97110) visit provided on July 13, 2023.