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

 
We decided that the Plan does not have to pay for the services (95861, 95957) provided on April 11, 2023. 
 
You asked the Plan to pay for the services. 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. 
 
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 use of codes 95861 
and 95957 is not supported by the records provided. Our reviewer found that for code 95861, the procedure 
report describes needle electromyography (EMG) 1 extremity. In this case, there is a more specific procedure 
code that would be reported for the service provided. For code 95957, the medical record describes 
neuromonitoring service provided for spinal procedures. The documentation does not support criteria for the procedure reported. Digital electroencephalogram (EEG) spike analysis (CPT code 95957) performed in 
conjunction with an EEG is considered medically necessary for topographic voltage and dipole analysis in 
presurgical candidates with intractable (e.g., medically refractory, drug-resistant) epilepsy.  Therefore this 
procedure cannot be verified. 
 
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 (95861, 95957) provided on April 11, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee as age-related osteoporosis 
without osteoporotic fracture. She has not tried and failed the Plan's required drugs, an oral bisphosphonate or 
zoledronic acid. The records do not show that the required drugs would be contraindicated or less effective; 
therefore, Prolia 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of a permanent cardiac 
contractility modulation system (0408T). 
 
You asked the Plan to pre-approve the Optimizer Smart system. You say that the enrollee has suffered from 
dyspnea on exertion and the requested system is medically necessary. The Plan denied your request. The Plan 
says a review of the current medical literature indicates that this service is considered experimental and 
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 the Optimizer Smart system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found an exhaustive review of the current medical literature pertaining to the 
cardiac contractility modulation (CCM) system confirms multiple observational studies suggesting clinical 
benefit from CCM. Several randomized clinical trials of CCM versus control have also been reported, along 
with meta-analysis pooling the data from multiple studies, with CCM providing meaningful improvement in 
quality-of-life scores and objective functional capacity. While the clinical studies led to Food and Drug 
Administration (FDA) approval in 2019, CCM remains the subject of multiple studies examining long-term 
efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such 
statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the 
current time, the reviewer would not consider the CCM system to be medically necessary in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Optimizer Smart system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve insertion or replacement of a permanent cardiac contractility modulation 
system (0408T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 29, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 19, 2023, billed 
with codes 81162-90, 81201-90, 81218-90, 81292-90, 81295-90, 81298-90, 81307-90, 81317-90, 81321-90, 
81351- 90, 81209-90, 81314-90, 81334-90, 81345-90, 81272-90, 81479-90-GY x3. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachments and 
reconsider the charges which were previously denied. 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 
February 19, 2023, billed with codes 81162-90, 81201-90, 81218-90, 81292-90, 81295-90, 81298-90, 81307-
90, 81317-90, 81321-90, 81351- 90, 81209-90, 81314-90, 81334-90, 81345-90, 81272-90, 81479-90-GY x3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that the requested CGM allows 
you to dose medication accordingly. The Plan denied your request. The Plan says you do not meet criteria for 
approval of the requested CGM. 
 
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 you do not have diabetes, use 
insulin or have a history of problematic hypoglycemia, had an in-person visit with your treating physician to 
evaluate your diabetes control and to determine whether the criteria for coverage have been met. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre 2 CGM sensor have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM) sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry care provided on January 5, 2022. 
 
You asked the Plan to pay for the podiatry care. The Plan denied your request. The Plan says this service does 
not meet the coverage requirements in the applicable Local Coverage Determination (LCD) or National 
Coverage Determination (NCD). 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
podiatry care have not been met. Therefore, we decided that the Plan does not have to pay for podiatry care 
provided on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit and debridement provided on November 11, 
2022. 
 
You asked the Plan to pay for the home visit and debridement. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit and 
debridement provided on November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth consultation provided on May 23, 2023. 
 
You asked the Plan to pay for the telehealth consultation. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the telehealth 
consultation provided on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 17, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the OON medical services. You say that the patient is known to your office for a 
history of melanoma. You say that this is a continuation of care for another melanoma that you noticed on his 
right lower extremity. The Plan denied your request. The Plan says the services in dispute were not approved in 
advance.  
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services from an OON 
provider. Therefore, we decided that the Plan does not have to pay for medical services provided on April 17, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on June 22, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that the service was medically necessary. You 
also say that the enrollee was referred for these services. The Plan denied your request. The Plan says prior 
authorization was not obtained for the provider in this case.  
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue 
with this provider. We found no exception that would require the Plan to pay for this service. Therefore, we 
decided that the Plan does not have to pay for the office visit (99214) provided on June 22, 2023, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT) (77014, 77470, 
G6015). 
 
You asked the Plan to pre-approve IMRT. You say that the enrollee has had previous radiation therapy in close 
proximity and the provider feels like this is absolutely necessary. The Plan denied your request. The Plan says 
that there is no high-quality evidence that this type of radiation therapy is needed or effective for the enrollee's 
cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is being offered palliative radiation to the thoracic spine. The records claim that the 
prior radiotherapy necessitates IMRT. The prior radiation (80 gray (Gy) in 40 fractions pelvic radiation for the 
prostate cancer which the records erroneously state completed in December 2023, and stereotactic body 
radiotherapy (SBRT) for nodal recurrence in the abdomen or pelvis) potentially overlap with the current 
treatment. It would not be safe or prudent to treat without the past radiation records (preferably submitted in 
Digital Imaging and Communications in Medicine (DICOM) format) though it sounds like the radiation 
oncologist is obtaining those records. Given the likely overlap with prior treatment and the need to start 
radiation expediently, the decision is favorable for 10 fractions of IMRT/image guided radiation therapy 
(IGRT) as this would be standard of care in the setting of prior radiotherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
intensity-modulated radiation therapy (IMRT) (77014, 77470, G6015).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says you 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable with no acuity and no recent hospitalization and does not 
need physical medicine and rehabilitation (PMR) physicians supervision 3 times a week in an IRF. No acute 
rehab skilled nursing needs identified or documented. At the current functional level, you need routine physical 
therapy (PT) and occupational therapy (OT), and you do not need specialized intensive therapies consisting of 
at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. 
Document does not support necessity for admission to an IRF. IRF Admission is not necessary and reasonable. 
your rehab needs can be provided in an alternate and low intensity setting such as continued in an SNF or 
continued services at assisted living facilities (ALF).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on July 28, 2021. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. The Plan denied your request. The Plan says based on 
Medicare guidelines, the non-invasive ventilator (NIV) requested does not meet the requirements for approval. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the patient has severe COPD 
and was recently hospitalized with an exacerbation. The arterial blood gas analysis was consistent with acute 
on chronic hypercarbic respiratory failure. Our reviewer found that the patient also has severe obesity. The 
forced expiratory volume in the first second (FEV1) was 26% of predicted in October 2023. This patient may 
benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep as an outpatient. Our 
physician reviewer also found that the records do not show this has been tried as an outpatient. Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).