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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are unable to walk, and you need physical and 
occupational therapy to regain full function. The Plan denied your request. The Plan says the SNF services 
requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar interspinous process stabilization device without decompression or fusion (Vertiflex procedure) (22869, 22870).

You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says interspinous decompression systems (without fusion) for the treatment of spine pain or spinal stenosis are unproven and not medically necessary due to insufficient evidence of efficacy.

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 Vertiflex procedure. Our reviewer says that the requested Vertiflex procedure not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is considered experimental as additional research is needed.
Therefore, the reviewer found that the requested Vertiflex 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 the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar interspinous process stabilization device without decompression or fusion (Vertiflex procedure) (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guidance radiation therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that you are in dire need of having these services and it may 
affect your health if you do not have them in a timely manner. The Plan denied your request. The Plan says 
there is not enough medical evidence to show that this type of radiation treatment is effective to treat your skin 
cancer. 
 
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 items/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 you for which the target lesion can be 
seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT 
unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable to offer 
but not necessary. The device itself is Food and Drug Administration (FDA) approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was 
designed to incorporate this functionality. Therefore, to bill for daily simple simulations (77280) and/or IGRT 
for a technology for which need has not been established by published data or supported by consensus 
guidelines (many of which recommend against treatment with these devices in general) is not necessary. The 
decision is unfavorable as billing for daily IGRT which would not be furnished in accordance with accepted 
standards of medical practice. 
 
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 guidance radiation therapy (IGRT) (G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 15, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on June 30, 2023. 
 
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 June 30, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service June 22, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says that the date of service on the claim is inconsistent with the date on the 
medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The date of service on the claim matches the date the testing was 
performed. The Plan has not shown that the date of service is incorrect. The Plan has not shown that the sample 
did not meet one of the exceptions. Based on this information, we decided that Medicare rules for coverage of 
the billed services have been met. Therefore, we decided that the Plan has to pay for the lab testing billed for 
date of service June 22, 2022.  
 
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 97598 billed for date of service July 13, 
2023. 
 You asked the Plan to pay for procedure code 97598. You say that the medical documentation supports 
separate reimbursement. The Plan denied your request. The Plan says payment for code 97598 is bundled into 
payment for code 11043. 
 
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, we have confirmed that code 97598 is a column II code to column I code 11043. Code 97598 has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 97598 
billed for date of service July 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug 
classes (G0482) provided on January 10, 2023. 
 
You asked the Plan to pay for the definitive UDT for 15-21 drug classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says ordering a multi-class panel of definitive 
(confirmation) urine drug tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in 
the rules section of this letter 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 pay for the definitive UDT for 15-21 drug classes. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
documentation does not support that definitive multi-drug testing was medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the definitive UDT for 15-21 drug classes have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive urine drug testing (UDT) for 15-21 drug classes (G0482) provided on 
January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on March 20, 2023. 
 
You asked the Plan to pay for that 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 that panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on March 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E1399 and E0627). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that the requested seat lift mechanism is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a seat 
lift mechanism. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 a seat lift mechanism. Our reviewer says that the enrollee does not meet criteria for a seat lift mechanism. Our physician reviewer found the 
enrollee is with a medical history of osteoarthritis of the hip and knee joints. Other conditions are notable for 
Rheumatoid arthritis, and atrial fibrillation. A clinical progress noted dated June 23, 2023, indicated that the 
enrollee was coaching softball and working out at the gym. The enrollee was evaluated by physical therapy on 
September 10, 2023, after being evaluated in the emergency department for worsening stiffness and pain. He 
was noted to have difficulty with getting out of bed and moving. The enrollee was admitted to a skilled nursing 
facility on September 12, 2023. The enrollee was noted to have 4/5 motor strength in the upper extremities and 
3/5 motor strength in the lower extremities. The enrollee was noted to have good standing balance and was able 
to independently transfer and ambulate with a single point cane. The enrollee is noted to have osteoarthritis of 
the hip and knee joints. However, the therapy documentation indicates that the enrollee is independent with sit 
to stand transfers and can ambulate independently with a single point cane. Therefore, the power seat lift chair 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism (E1399 and E0627).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service April 5, 2022, 
to May 4, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical documentation was provided. The Plan 
denied your request. The Plan says the service was billed with an incorrect code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim at issue was billed with HIPPS code 2J231, indicating an early 
institutional admission. An early admission is for the first 30-day period of care. The enrollees records do not 
show that this period of care was the initial period. 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 the home health care billed for dates of service April 5, 2022, to May 4, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the TissueCypher Barrett's esophagus assay (0108U) provided on July 
12, 2023. 
 
You asked the Plan to pay for the TissueCypher Barrett's esophagus assay. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says that this assay for determining the risk of 
progression from Barrett's esophagus to high grade dysplasia or cancer remains unproven. 
 
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 pay for the TissueCypher Barrett's esophagus assay. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found that the TissueCypher test is medically reasonable and necessary in the 
setting of the diagnosis of Barrett's esophagus with inclusion in some clinical guidelines. 
 
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 TissueCypher Barrett's esophagus assay have been met. Therefore, we 
decided that the Plan has to pay for the TissueCypher Barrett's esophagus assay (0108U) provided on July 12, 
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 pay for the lab testing billed for date of service May 30, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the test was provided at the request of the 
physician. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service May 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 8, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the diagnosis code at 
issue is not appropriate as a primary diagnosis.  
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code F02.C11. This 
code is not an appropriate primary diagnosis as the code definition includes in diseases classified elsewhere 
which means it is a manifestation code. Based on this information, we decided that Medicare rules for payment 
of this claim have not been met. Therefore, we decided that the Plan does not have to pay for the services 
provided on March 8, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 19, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99222, 99232, 99238, and 99497 for date of 
service January 29, 2023, to January 31, 2023. 
 
You asked the Plan to pay for procedure codes 99222, 99232, 99238, and 99497. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services billed 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 find that CPT codes 99222, 99232, 99238, and 99497 are not supported in the medical record. Specifically, 
the submitted medical records do not include the actual date of service. Without this documentation, the 
services cannot be validated. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 99222, 99232, 99238, and 99497 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99222, 99232, 99238, and 99497 for date of service January 29, 2023, to 
January 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation, including cavity 
creation, using mechanical device (22513). 
 
You asked the Plan to pre-approve kyphoplasty. You say that you disagree with the denial. The Plan denied 
your request. The Plan says medical necessity is not demonstrated because there is insufficient documentation 
of reevaluation after a trial of non-surgical management. 
 
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 kyphoplasty. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no trial of fracture bracing, therefore, the enrollee does not meet criteria for 
kyphoplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous vertebral augmentation, including cavity creation, using mechanical device 
(22513).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12052 billed for date of service June 8, 2023. 
 
You asked the Plan to pay for the billed service. You say that medical records were provided.  The Plan denied 
your request. The Plan says the billed code is 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 12052 is repair, intermediate, wounds of face, ears, 
eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm. We find that CPT code 12052 is not supported 
in the medical record. The records show that a simple repair was provided. There is a more applicable code 
available that describes the services provided. The file also shows that the wound repair was provided in the 
emergency room. The physician who performs the emergency room service bills for the surgical procedure 
without a modifier. Based on this information, we decided that Medicare rules for coverage of the billed service 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 12052 billed 
for date of service June 8, 2023.