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

 
We decided that the Plan does not have to pay for the blood count; complete (CBC) (85025) and hemoglobin; 
glycosylated (A1C) test (83036) provided on November 28, 2022. 
 
You asked the Plan to pay for the CBC and A1C tests. You say that you were not informed that these tests 
would not be covered. The Plan denied your request. The Plan says screening tests are not covered, and you 
signed a financial waiver form prior to the services being rendered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the CBC and A1C tests, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the blood count; complete (CBC) (85025) and hemoglobin; glycosylated (A1C) test (83036) provided on 
November 28, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided August 8, 2022, to August 10, 
2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that observation level of care would have been more 
appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided August 8, 2022, to August 10, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a patient lift (E0635) purchased on July 13, 2022. 
 
You asked the Plan to reimburse you for a patient lift. You say that this item is medically necessary. The Plan 
denied your request. The Plan says the provider is not certified with Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services from either Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the 
Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a patient lift have not been met. Therefore, we decided that the Plan does not have to reimburse 
you for a patient lift (E0635) purchased on July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria 
 
The Plan follows Medicare rules.  
 
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 an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case. 
Our physician reviewer found that the enrollee has had prior epidural steroid injections for his spinal stenosis 
and degenerative disc disease. One progress note states 30-40 percent and another states 80 percent pain relief. 
The duration of pain relief however is less than three (3) months. The Medicare LCD requires 50% pain relief 
for three (3) months. This does not appear to have been achieved and therefore, the request is deemed not 
medically reasonable and 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of permanent cardiac 
contractility modulation system, including contractility evaluation when performed, and programming 
(Optimizer Smart pulse generator) (0408T). 
 
You asked the Plan to pre-approve Optimizer Smart pulse generator. You say that the enrollee needs this 
procedure. The Plan denied your request. The Plan says the requested 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 Optimizer Smart pulse generator. Our 
reviewer says that the requested Optimizer Smart pulse generator is not considered medically reasonable and 
necessary in this case. Our physician reviewer found while the clinical studies have led to Food and Drug 
Administration (FDA) approval in 2019, cardiac contractility modulation (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. Therefore, the reviewer found that the requested Optimizer Smart pulse 
generator is not medically reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Optimizer Smart pulse generator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve insertion or replacement of permanent cardiac contractility modulation 
system, including contractility evaluation when performed, and programming (Optimizer Smart pulse 
generator) (0408T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2377, E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says that the upgraded electronics are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are covered when it is medically 
necessary for the enrollee to control the power options through the joystick. 
 
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 upgraded electronics. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that you have adequate strength 
in your upper extremities to manage multiple standard power drives. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2377, E2313).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided February 7, 2022, 
to February 8, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an admission was medically 
necessary. The Plan denied your request. The Plan says an inpatient admission for an ischemic stroke is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the provided documentation, the enrollee was not expected to require 
hospital services that would likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided February 7, 2022, to February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96375-59 provided on April 27, 2022. 
 
You asked the Plan to pay for procedure code 96375-59. You say that the medical records support the use of 
modifier 59 with code 96375. The Plan denied your request. The Plan says the medical records do not support 
the use of modifier 59 with code 96375. 
 
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 96375 is a column II code to column I codes 64483 and 99152; 
however, 96375 was billed with a modifier.  
 
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 procedure code 96375-59. Our reviewer says that the medical 
records do not support the use of modifier 59 with code 96375. Our reviewer found the medical record does not 
include documentation to support that this injection was a separate procedure from moderate sedation as well 
as the anesthetic injection. Based on the documentation provided, was unable to cite documentation to support 
modifier -59, as is not documented, and therefore 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 procedure code 96375-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 96375-59 provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain/ceramic (D2740) Tooth #14. 
 
You asked the Plan to pay for dental services. You say that you feel the services should be covered. 
 The Plan denied your request. The Plan says the crown - porcelain/ceramic (D2740) was denied but they have 
determined to change to a less expensive treatment crown - porcelain fused to predominantly base metal 
(D2751). 
 
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. The Plan covers dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our physician reviewer 
found the outcome of the function of either of these crowns would be the same. There was no documentation 
that one was preferred due to medical issues such as allergy to materials or various occlusal issues. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pay for a crown - porcelain/ceramic (D2740) Tooth #14.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you believe that to get the best 
care from your caregivers and daughter, you need a fully automatic bed, and you are willing to pay the 
difference. The Plan denied your request. The Plan says the requested bed is not covered as the height 
adjustment feature is a convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received from a 
Licensed Marriage and Family Therapist (LMFT). 
 
You asked the Plan to pay for the LMFT services. You say that you paid this provider in full and are requesting 
reimbursement for your mental health counseling. The Plan denied your request. The Plan says you saw a 
provider that is not eligible to participate in Medicare, so these services are not covered. 
 
The Plan covers services in accordance with Medicare rules.  Medicare rules state that only certain providers 
are eligible to provide mental health services. Licensed Marriage and Family Therapists (LMFTs) are not 
eligible providers, so no benefit exists for outpatient mental health services provided by LMFTs for patients 
with Medicare. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LMFT services have not been met. Therefore, we decided that the Plan does not have to pay for 
outpatient mental health services you received from a Licensed Marriage and Family Therapist (LMFT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87653, 87798) provided on April 12, 
2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 find that CPT codes 87481, 87653, & 87798 are not supported in the medical record. Specifically, codes 
87481, 87653, & 87798 are included in code 87801 which was approved by the plan. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (87481, 87653, 87798) provided on April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need these items. The Plan denied 
your request. The Plan says this item is not covered under Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) show scoliosis and foraminal stenosis. The 
cause of the back pain is unclear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure, PrismRA test 
(81479) provided December 2, 2022 
 
You asked the Plan to pay for the PrismRA testing. You say that you are requesting reconsideration of the 
denial for coverage and payment for PrismRa testing. The Plan denied your request. The Plan says under 
Medicare guidelines, this request is not medically necessary because the records show this test is not FDA approved and based on the diagnostic program, MolDX Technical Assessment, the requested PrismRA test is 
not an approved test. 
 
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 PrismRA testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found review indicates that the enrollee has rheumatoid arthritis (RA). The record sent by the test 
provider documents that this test, PrismRA has not been cleared or approved by the FDA. Online search of 
the FDA list of cleared or approved companion diagnostic testing does not mention this PrismRA 
 
Per the literature, although there is apparent need and clinical utility for identifying appropriate 2nd line 
therapy with biologics in RA patients, the current evaluated tests that measure genetic and gene expression 
factors have not yet demonstrated definitive value above the combination of available clinical, laboratory, and 
demographic data, which are also known to provide some predictive information regarding response to tumor 
necrosis factor (TNF). Therefore, clinical validity has not yet been established for molecular biomarker tests 
that guide targeted therapy selection in RA. The review has determined that the items/services at issue in this 
case are 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 PrismRA testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the unlisted molecular pathology procedure, PrismRA test (81479) provided December 
2, 2022
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision of excessive skin and subcutaneous tissue. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says followup with the doctor is encouraged regarding the next steps in the treatment plan. 
 
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 services. 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 enrollee's intertrigal dermatitis is refractory to usual 
standard medical therapy. 
 
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 pre-approve excision of excessive skin and subcutaneous tissue.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth consultation (code G0426) provided on 
December 25, 2022. 
 
You asked the Plan to pay for the telehealth consultation. You say that your company has an exclusive contract 
with the facility and your doctors are the only providers who will treat the patients. The Plan denied your 
request. The Plan says no authorization was obtained. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a telehealth consultation (code G0426) provided on 
December 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control (E2331). 
 
You asked the Plan to pre-approve an attendant control. You say that  The Plan denied your request. The Plan 
says this item is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in 
addition to a beneficiary-operated drive control system, it will be denied as non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an attendant control have not been met. Therefore, we decided that the Plan does not have to pre-
approve an attendant control (E2331).