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

 
We decided that the Plan does not have to pay for procedure code 99458 billed for date of service March 23, 
2023.  
 
You asked the Plan to pay for procedure code 99458. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99458 is 3. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99458 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99458 billed for date of service March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service February 10, 
2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A4239 is considered bundled and not separately payable.  
 
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 A4239 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4239 is not separately payable/excluded. Based on this information, we decided that 
Medicare rules for coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A4239 billed for date of service February 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral L4-5 and L5-S1 radio frequency ablations. 
 
You asked the Plan to pre-approve a bilateral radio frequency ablations. You say that you need this procedure. 
The Plan denied your request. The Plan says this procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a bilateral radio frequency ablations. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found documentation provided is not adequate enough to cover the requested 
service. 
 
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 bilateral radio frequency ablations have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a bilateral L4-5 and L5-S1 radio frequency ablations.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for inpatient 
rehabilitation. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services billed with code J3490 for February 20, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that introaperative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same day as 
minor surgical procedure 64493. Payment for code J3490 is included in the global surgical package for 64493. 
Therefore, we decided that the Plan does not have to pay for the drug services billed with code J3490 for 
February 20, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 You asked the Plan to pre-approve Ilumya. You say that the enrollee has tried methotrexate. The Plan denied 
your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for Ilumya. 
 
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 Ilumya. Our reviewer says that the 
enrollee does not meet the coverage criteria for Ilumya. Our physician reviewer found the Plan requires a trial 
of Remicade, Inflectra or Infliximab; and Stelara before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. Our reviewer also found that there is no documentation 
provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse 
effects for the 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya (J3245).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus xG genetic testing panel provided on May 23, 2022. 
 
You asked the Plan to pay for the Tempus xG genetic testing panel. You say that the enrolles provider 
regarded this test as medically necessary to determine treatment. The Plan denied your request. The Plan says 
that criteria for coverage are not met. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the Tempus xG genetic testing panel by a contract provider. The file does not 
show that the plan provided notice that the Tempus xG genetic testing panel would not be covered. Under 
Medicare rules, this means the Tempus xG genetic testing panel is considered approved by the plan. Therefore, 
we decided that the Plan has to pay for the Tempus xG genetic testing panel provided on May 23, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS testing provided on October 3, 2022.  
 
You asked the Plan to pay for the WATS testing. You say that this testing was medically necessary since it is a 
proven superior method of acquiring and analyzing esophageal tissue. The Plan denied your request. The Plan 
says this testing is considered experimental.  
 
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 WATS testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that while there is early clinical data supporting the use of WATS for Barrett's Esophagus, 
WATS is not the standard of care. WATS is experimental and was not medically necessary in this case. 
 
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 WATS testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the WATS testing provided on October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628) and a thermal 
destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, 
lumbar or sacral (64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that you believe the enrollee needs this 
treatment to get relief from back pain. The Plan denied your request. The Plan says the requested procedure is 
currently considered to be experimental/investigational (not proven with research) and therefore is not a 
covered benefit of the enrollee's plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an Intracept procedure have not been met. Specifically, the requested procedure is considered 
experimental/investigational and not a covered benefit with the plan. Therefore, we decided that the Plan does 
not have to pre-approve a thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628) and a thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on January 25, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for acupuncture services. You say that this was previously covered. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for acupuncture services provided on January 25, 
2023, by an out-of-network (OON) provider.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet the admission requirements. Services 
needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 the family is unable to care for the enrollee at home. 
The Plan denied your request. The Plan says the SNF services you are requesting 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infrared light therapy provided from September 1, 2022, to 
October 12, 2022. 
 
You asked the Plan to pay for Infrared light therapy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Infrared therapy is considered not reasonable and necessary by 
Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. 
 We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for Infrared light therapy provided from September 1, 2022, to 
October 12, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve parathyroid planar imaging. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested service is not covered by Medicare or the health plan. 
 
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 the imaging. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that you have an elevated parathormone level and chronic renal disease.  A nuclear medicine planar 
study is the procedure of choice to diagnose whether the elevated parathormone level indicates primary 
hyperparathyroidism due to hyperplasia or a parathyroid adenoma. A consideration of surgery is not possible 
without knowing the etiology of the elevated parathormone level. The exam should be approved. 
 
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 imaging have been met. Therefore, we decided that the Plan has to pre-
approve parathyroid planar imaging.  
 
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 initial hospital care (99222) billed for date of service January 
17, 2023. 
 
You asked the Plan to pay for initial hospital care. 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. Medicare rules say that the inpatient or outpatient hospital POS code 
would be reported regardless of where the face-to-face service takes place.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of initial hospital care have not been met. Specifically, the case record supports that the enrollee was 
in outpatient observation status on the date of service. The claim at issue was inappropriately billed with POS code 21, indicating inpatient services. Therefore, we decided that the Plan does not have to pay for initial 
hospital care (99222) billed for date of service January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 
22, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 22, 2023.
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 is able to tolerate 15 hours of therapy a 
week, expected to make reasonable progress from and actively participate in an intensive rehab program, 
requires medical physician oversight for ongoing clinical conditions and active co morbidities. He requires and 
will benefit from an interdisciplinary team approach to their rehabilitation program. The Plan denied your 
request. The Plan says the enrollee's records do not show that you have a complex rehabilitation need that 
would necessitate evaluation by a rehabilitation doctor 3 times per week or require the intensity of 3 hours per 
day of therapies per day. Services needed may be provided safely in a lower level of care.  
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.