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

 
We decided that the Plan does not have to pay for cerebral perfusion analysis rendered on August 19, 2022. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no documentation of acute ischemic stroke (AIS) caused by unilateral large vessel 
occlusion (LVO) in the proximal anterior circulation. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the computed tomography angiography (CTA) of the head and neck on August 19, 2022 revealed no 
cerebrovascular accident (CVA), nor did it reveal any large vessel occlusive disease. Reimbursement for CT 
perfusion require the presence of such large vessel occlusive disease to qualify for such an extension of the 
CTA and no such occlusion is noted in the reports. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for cerebral perfusion analysis rendered on August 19, 2022.
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 does not 
meet the requirements. 
 
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 pre-approve a manual wheelchair with features. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that the request was submitted to the 
enrollee's Medicaid coverage. You also say that Medicare rules do not apply and as such cannot be used to 
determine the suitability of the chair in this case. The Plan denied your request. The Plan says the requested 
manual wheelchair is not a covered benefit when it is to be used in a long-term care facility. 
 
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 a manual wheelchair is being requested for use in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pre-approve a manual wheelchair with features.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intrapulmonary percussive ventilator (IPV) (E0481). 
 
You asked the Plan to pre-approve an intrapulmonary percussive ventilator. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested device is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that IPV in the home setting is not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the request is for IPV in the home 
setting. This is specifically not covered. Based on this information, we decided that Medicare rules for 
coverage of an intrapulmonary percussive ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intrapulmonary percussive ventilator (IPV) (E0481).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740), a pontic (D6245) and core 
buildup (D2950). 
You asked the Plan to pre-approve the dental services. You say that you say the enrollee needs a bridge to 
restore function. The Plan denied your request. The Plan says a clinical review of the documentation submitted 
for this claim determined the services do not meet the criteria for coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services cannot 
be approved until the dental records are received. Based on this information, we decided that the Plans rules 
for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-
approve retainer crowns (D6740), a pontic (D6245) and core buildup (D2950).
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 appropriate for the enrollee's 
admission to an inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee's records do 
not show you need to be seen by a rehabilitation physician at least 3 times a week for evaluation of functional 
and medical goals and progress or that you need an intensive team. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Combined Cardio/PGX panel provided on January 3, 
2023.  
 
You asked the Plan to pay for the Combined Cardio/PGX panel . You say that this testing is medically 
necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of comprehensive 
pharmacogenomics testing have not been demonstrated in the peer-reviewed literature.  
 The Plan follows Medicare rules. Medicare rules say that genetic testing is covered when it is medically 
necessary and meets the criteria in the rules section of this letter. 
 
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 Combined Cardio/PGX panel. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that the test is 
described as a genetic based cardiovascular risk factor screening test in which multiple genes are assessed 
using genomic DNA extracted from patient sampling. It assesses the presence of pathogenic or likely 
pathogenic variants in genes known to be associated with increased cardiac risk. It is not a diagnostic test. 
There is no evidence to support its role in this enrollees clinical management. In summary, the requested 
testing is not considered 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 the Combined Cardio/PGX panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the Combined Cardio/PGX panel provided on January 3, 2023.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided on January 3, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that this provider is licensed to bill Medicare. The 
Plan denied your request. The Plan says that Medicare does not cover behavior health services performed by a 
Social Worker.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a Medicare rule to substantiate their denial. This 
providers NPI 1700222031 is identified as a Licensed Clinical Social Worker. Therefore, we decided that the 
Plan has to pay for psychotherapy provided on January 3, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tempus xT test. 
 
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show that further treatment is being sought. 
 
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 test. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the coverage criteria for Tempus xT solid tumor genetic 
testing were met in this case. The documentation does not support that further therapeutic chemotherapy is an 
option for this enrollee. In addition, the Tempus Gene Panel does not have Food & Drug Administration 
approval or clearance as a companion in vitro diagnostic. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Tempus xT test.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 epidural steroid injections. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the transforaminal 
epidural steroid injection (TFESI) performed on March 6, 2023, provided an unknown percentage of pain relief 
for only 3 weeks. The review has determined that you do not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic continuous glucose monitor (CGM) and supplies 
provided on October 25, 2022. 
 
You asked the Plan to pay for therapeutic continuous glucose monitor (CGM) and supplies. You say that you 
are appealing the claim payment denial. 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 therapeutic continuous 
glucose monitor (CGM) and supplies provided on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter replacement. 
 
You asked the Plan to pre-approve a replacement scooter. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says that the enrollee's current power 
wheelchair is less than five years old and there is no evidence that it is unable to be repaired. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of equipment due to wear is not 
covered during the reasonable useful lifetime of the equipment. 
 
 The record shows you received a power scooter in May 2022. The record also does not show evidence that 
your current power scooter is unable to repaired. Therefore, we decided that the Plan does not have to pre-
approve a power scooter replacement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0339U provided on February 7, 2023. 
 
You asked the Plan to pay for procedure code 0039U. 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 covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes D29.1 and N40.0 should not be reported together. Therefore, we decided that the Plan does not 
have to pay for procedure code 0339U provided on February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tenodesis of long tendon of biceps rendered on October 21, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 23430 is "Tenodesis of long tendon of biceps."  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 23430 is included in the 
shoulder arthroplasty - CPT 23472. It should not be unbundled and not paid separately. 
 
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 tenodesis of long tendon of biceps rendered on October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided on December 16, 2022. 
 
You asked the Plan to pay for procedure code 99233. 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 covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes J96.01 and R09.02 should not be reported together. Therefore, we decided that the Plan does 
not have to pay for procedure code 99233 provided on December 16, 2022.
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 the enrollee's current condition and functional 
deficits, as well as multiple comorbidities, physician has determined that the enrollee meets full inpatient acute 
rehabilitation criteria. The Plan denied your request. The Plan says the enrollee's records do not show that you 
have complex rehabilitation needs requiring frequent evaluation by a rehabilitation doctor or that you require 
intensive therapies to improve your functional independence. 
 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: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says that the 
criteria for approval have not been met. 
 
The Plan must follow 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 continuous glucose monitor (CGM). 
Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee is on 
insulin and the service is 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 continuous glucose monitor (CGM) have been met. Therefore, we decided 
that the Plan has to pre-approve a continuous glucose monitor (CGM).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service  
September 20, 2022. 
 
You asked the Plan to pay for procedure code 99601. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
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 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service September 20, 2022.