Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 continuous glucose monitor 
(CGM).  
You asked the Plan to pre-approve the CGM. You say that the enrollee needs this CGM. The Plan denied your 
request. The Plan says the requested CGM is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia, nor had an in-person visit with their treating physician to evaluate 
their diabetes control and to determine whether the criteria for coverage have been met.  Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre 14 continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 36556. We decided that the Plan does not have to pay 
for procedure code 99053.  
 
You asked the Plan to pay for procedure codes 36556 and 99053 billed for date of service October 26, 2022.. 
You say that the services were billed appropriately. The Plan says that code 99053 is not separately payable. 
 
We decided that the Plan has to pay for procedure code 36556.  
 
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 file shows that procedure code 36556 was originally denied as the information submitted does not support 
this level of service. The Plan has not provided any information or Medicare rules to substantiate their denial. 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Therefore, we decided that the Plan has to pay for procedure code 36556 billed 
for date of service October 26, 2022.  
 
We also decided that the Plan does not have to pay for procedure code 99053. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99053 billed for date of service October 26, 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 pre-approve a pneumatic compression device (E0651) and a leg 
appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and a leg appliance. You say that you 
disagree with the denial and submitted medical records for review. The Plan denied your request. The Plan says 
the enrollee does not meet criteria for approval of the requested devices. The enrollee does not have detailed 
measurements over time confirming the persistence of lymphedema or have one or more venous stasis ulcers 
that have failed to heal. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0651) and a leg appliance (E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 3, 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 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 these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64635, 64636). 
 
You asked the Plan to pre-approve the RFA. You say that the enrollee's facet joints are patent. You say that you 
can sufficiently perform an RFA at the levels ordered. You also say that then enrollee has previously had 
bilateral RFA in May 2020 with 50% or great relief at that time. The Plan denied your request. The Plan says 
the records show that the enrollee has had back surgery in the same location as the requested procedure so other 
reasons for the pain cannot be excluded.  
 
The Plan follows Medicare rules. Medicare rules say that facet joint procedure performed after anterior lumbar 
interbody fusion (ALIF) is considered not medically reasonable and necessary.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the RFA. Our reviewer says that the 
requested RFA is not medically necessary. Our physician reviewer found the provided documentation indicates 
the enrollee has had a partial interbody fusion at the level to be injected. Therefore, the reviewer found that the 
requested RFA 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) (64635, 64636).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan has to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that the enrollee requires a CGM. The Plan 
denied your request. The Plan says that the requested CGM is not a preferred brand and therefore is not 
covered. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms 
indicate the preferred brands for a continuous glucose monitor.  
 
We looked at your contract with the Plan. We did not see where the contract says the preferred brands for a 
continuous glucose monitor. This means that the Plan did not follow Medicare rules for disclosure of cost 
sharing information. Therefore, we decided that the Plan has to pre-approve a Dexcom G6 continuous glucose 
monitor (CGM) and supplies.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 26, 2022, to 
February 24, 2022. 
 You asked the Plan to pay for the home health services. You say that you have supplied the NOA, so this claim 
should be paid. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 26, 2022. The NOA was not received by the Plan until March 10, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 26, 2022, to February 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93976 billed for date of service September 
30, 2022. 
 You asked the Plan to pay for procedure code 93976. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93976 is bundled into payment for code 76770. 
 
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 93976 
is a column II code to column I code 76770. This claim 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 93976 billed for date of service September 30, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute 
care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. All medically 
necessary care is being provided in the current acute care setting.  The health plan has approved ongoing care 
in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary.  
 
The enrollee is a 69-year-old with a medical history of diabetes mellitus type II, hypertension, chronic kidney 
disease, hyperlipidemia, and coronary artery disease. The enrollee underwent a left sided transtibial amputation 
on January 4th, 2023, and was discharged home with home health services, including physical therapy. 
Documentation dated May 9th, 2023, indicated that the enrollee was evaluated for a left transtibial prosthesis. 
Documentation dated May 2nd, 2023, indicated that the enrollees residual limb has completely healed. The 
enrollee was noted to have the potential to be a K3 level ambulator. As of May 25th, 2023, the enrollee was 
independent with sitting. The enrollee requires some assistance with standing and uses crutches for mobility. 
The enrollee is independent with bed mobility and ambulates 100 feet with crutches with supervision. 
Documentation dated June 4th, 2023, indicated that the enrollee was discharged from home health physical 
therapy as the enrollees goals were met and the enrollee will be starting outpatient physical therapy. 
 
The enrollee underwent a left sided transtibial amputation on January 4th, 2023, and has received home health 
physical therapy and skilled nursing care since being discharged from the hospital. The documentation 
indicates that the enrollee no longer requires home health physical therapy and will be starting outpatient 
physical therapy to walk with the enrollees prosthesis. The enrollees residual limb has healed so the enrollee 
does not require skilled nursing care for wound care. 
 
Therefore, the continued home health physical therapy 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Percepta Bronchial Genomic Classifier (81479). 
 
You asked the Plan to pay for Percepta Bronchial Genomic Classifier. You say that the Percepta test has strong 
clinical evidence to support clinical utility for patients with lung cancer. The lab test was medically necessary 
and is supported by medical records. The Plan denied your request. The Plan says the enrollee's records do not 
show that the bronchoscopy was non-diagnostic. Additionally, the enrollee had a high pre-test risk of 
malignancy based upon the size of the lesion, and this was concordant with the doctor's impression of risk.  
 
The Plan follows Medicare rules. Medicare rules say that coverage for Percepta Bronchial Genomic Classifier 
requires physician-assessed low or intermediate pretest risk of malignancy. 
 
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 Percepta Bronchial Genomic Classifier. Our 
reviewer says that this service is not medically necessary. Our physician reviewer found that the enrollee does 
not have a physician-assessed low or intermediate pretest risk of malignancy based upon the applicable clinical 
characteristic stratification.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Percepta Bronchial Genomic Classifier have not been met. Therefore, we 
decided that the Plan does not have to pay for Percepta Bronchial Genomic Classifier (81479).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64615 for date of service December 21, 
2021. 
 
You asked the Plan to pay for procedure code 64615. 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. 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 64615 is chemodenervation of muscle(s); muscle(s) 
innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine). 
 
 
 
 We find that CPT code 64615 is not supported in the medical record. Specifically, the claim did not include 
location of where the service was rendered. Based on this information, we decided that Medicare rules for 
coverage of procedure code 64615 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 64615 for date of service December 21, 2021.
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 these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no magnetic resonance imaging 
(MRI) showing only modic endplate changes without foraminal stenosis or facet degenerative joint disease. 
The Intracept procedure is therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from October 28, 2022, to 
November 26, 2022. 
 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 the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 28, 2022. The NOA was not received by the Plan until November 
16, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from October 28, 2022, to November 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar sympathetic nerve block.  
 
You asked the Plan to pre-approve the requested nerve block. You say that the enrollee has failed conservative 
management and should be allowed to have this nerve block.  The Plan denied your request. The Plan says due 
to the lack of effectiveness of the previous nerve block, this is not considered reasonable and necessary at this 
time.  
 
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 requested nerve block. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a female who suffers from complex regional pain syndrome (CRPS) 
type 1. On May 15, 2023, she had a lumbar sympathetic block, and it gave her 10% pain relief. The request is to repeat the sympathetic block. 
 
Our physician indicates that serial sympathetic blocks are not considered evidence-based therapy for CRPS 
type 1. The request is 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 the requested nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lumbar sympathetic nerve block.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service November 
25, 2022.   
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. 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 99285 is 1 The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. One unit of this service was already processed/paid by the Plan. 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 
99285 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99285 
billed for date of service November 25, 2022.