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

 
We decided that the Plan does not have to pay for the lipid panel (80061) performed on March 30, 2023.  
 
You asked the Plan to pay for the lipid panel. You say that this test was medically necessary. The Plan denied 
your request. The Plan says this service is not covered. 
 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 lipid panel, 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 
lipid panel (80061) performed on March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options, patient weight capacity up to and including 300 pounds (K0861) and additional items and 
accessories (codes: E2361 x2, E2373, E2377, E2313, E1007, E2300, E2620, E0955, E1028 x3, E1012, E0956 
x2, and E2311) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network DME. You say that the enrollee has multiple sclerosis 
(MS) which is a progressive degenerative condition and there are no other providers in the area that can 
provide the customized equipment they need. You also say that you would like a network exception to be 
granted in the enrollee's case so they can get the services provided that they need.  The Plan denied your 
request. The Plan says the requesting provider is not participating with the Plan. The Plan also says the records 
do not show the wheelchair and accessories are urgent and emergent.  
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider at issue in this case is not a network provider with the Plan. 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 out-of-network DME. Our physician reviewer found the documentation 
available for review does not support that there is a medical need for out-of-network DME. 
 
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 out-of-network DME have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the out-of-network DME. Therefore, we decided that 
the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple power options, 
patient weight capacity up to and including 300 pounds (K0861) and additional items and accessories (codes: 
E2361 x2, E2373, E2377, E2313, E1007, E2300, E2620, E0955, E1028 x3, E1012, E0956 x2, and E2311) to 
be provided by an out-of-network 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 in consideration of the enrollee's prior medical 
history, active comorbidities, and risk for medical instability while increasing activity, the IRF setting is the 
most appropriate to reach the desired outcomes. The Plan denied your request. The Plan says admission to an 
IRF is not medically necessary.  
 
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. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep test (HST) (G0398).  
 
You asked the Plan to pre-approve the testing. You say that this request does not meet medical necessity.  The 
Plan denied your request. The Plan says  the enrollee has developed issues with use of CPAP and wishes to be 
evaluated for the inspire device. The Plan also says that a new sleep test would be required for the inspire 
evaluation.  
 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 testing. Our physician reviewer 
found the sleep study is being ordered because the enrollee wishes to consider the Inspire device. There is no 
documentation of CPAP intolerance, and treatment with CPAP is effective, so the enrollee does not meet 
criteria for the Inspire device. There has been no major change in the enrollee's health status or body weight, so 
a repeat sleep study is not medically necessary. The denial is upheld. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a home sleep test (HST) (G0398).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chondrocyte injection (27412). 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says there are not enough studies showing this injection will improve health 
care decisions or health outcomes. 
 
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 injection. Our reviewer says that the 
requested chondrocyte injection is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. There is no provided diagnostic 
imaging corroboration of an osteochondral lesion of the right knee. Further studies are needed for this treatment 
modality to be an accepted standard of practice. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
chondrocyte injection 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a chondrocyte injection (27412).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 7, 2023, billed with 
codes 88185, 81339, 81403, 81219, 81270, and G0452. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the records provided. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 7, 2023, billed with codes 88185, 81339, 81403, 81219, 81270, and G0452.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the imaging services coded as 72129, 72126, and 72132 performed on 
March 24, 2023. 
 
You asked the Plan to pay for 72129, 72126, and 72132. You say that codes 72129, 72126, and 72132 are 
supported in the documentation. The Plan denied your request. The Plan says that no separate payment is 
warranted for 72129, 72126, and 72132 because the payment for 72129 is bundled into payment for 72128, 
payment for 72126 is bundled into payment for 72125, and payment for 72132 is bundled into payment for 
72131, performed on the same day by the same provider. The Plan also says that documentation does not 
support that 72129, 72126, and 72132 were performed on March 24, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that plans must make 
reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). 
 
 In this case, the CPT Code Manual definition of code 72129 is computed tomography, thoracic spine, with 
contrast material. The CPT Code Manual definition of 72126 is computed tomography, cervical spine, with 
contrast material. The CPT Code Manual definition of 72132 is computed tomography, lumbar spine, with 
contrast material. 
 
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 72129, 72126, and 72132. Our reviewer says that codes 
72129, 72126, and 72132 are supported in the documentation. Our reviewer found the record shows that post-
myelography computed tomography (CT) scans with contrast were taken of the cervical, thoracic, and lumbar 
spine, so it is confirmed that these procedures were performed.  
 
We looked at this coder's review, the file, and Medicare rules. We confirmed that 72129, 72126, and 72132 are 
column I codes to column II codes 72128, 72125, and 72131. The NCCI edits do not support the denial of 
column I codes provided on the same date of service as column II codes when the column II codes are missing 
appropriate modifiers. Based on this information, we decided that Medicare rules for coverage of 72129, 
72126, and 72132 have been met. Therefore, we decided that the Plan has to pay for the imaging services 
coded as 72129, 72126, and 72132 performed on March 24, 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: 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's current needs do not meet the guidelines for care in 
an inpatient rehabilitation facility or a skilled nursing facility. The Plan says services needed may be provided 
in a home based setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the equipment is medically 
necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continuous glucose monitor. Our 
reviewer says that the continuous glucose monitor is medically necessary. Our physician reviewer found the 
records show the enrollee has a history of severe hypoglycemia which required hospitalization. 
 
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 continuous glucose monitor have been met. Therefore, we decided that the 
Plan has to pre-approve a continuous glucose monitor.  
 
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: Favorable

 
We decided that the Plan has to pre-approve the suprascapular nerve block. 
 
You asked the Plan to pre-approve the suprascapular nerve block. You say that the suprascapular nerve block 
could be beneficial in confirming the diagnoses. The Plan denied your request. The Plan says that the 
suprascapular nerve block is not medically necessary. 
 
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 suprascapular nerve block. Our 
reviewer says that the suprascapular nerve block is medically necessary. Our physician reviewer found that this 
is a diagnostic procedure to evaluate frozen shoulder syndrome. Therefore, the request is 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 suprascapular nerve block have been met. Therefore, we decided that the 
Plan has to pre-approve the suprascapular nerve block.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy and lipectomy. 
 
You asked the Plan to pre-approve inner thigh lift, and a lower body lift. You say that the plan cannot approve 
this surgery because based on the medical notes, this surgery is purely cosmetic. The Plan denied your request. 
The Plan says the enrollee has lost a lot of weight, and these procedures would help the enrollee. 
 
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 inner thigh lift and a lower body lift. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the record indicates that the enrollee underwent bariatric surgery in 
August 2022, less than 18 months ago, and has had significant weight loss. The record provided is also 
insufficient to establish that the other required criteria are satisfied. The elements of the coverage criteria are 
not satisfied.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inner thigh lift, and a lower body lift have not been met. Therefore, we decided 
that the Plan does not have to pre-approve panniculectomy and lipectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a large size hospital bed. 
 
You asked the Plan to pre-approve the large size hospital bed. You say that the larger hospital bed is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, 
E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the 
beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. The record does not show that the enrollee weighs more than 350 
pounds. A standard size hospital bed was already approved. Based on this information, we decided that 
Medicare rules for coverage of the large size hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a large size hospital bed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve (Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment. You also say that the enrollee's pain is disabling and affecting their quality of life. The 
Plan denied your request. The Plan says this procedure is considered experimental and investigative and 
therefore, and not covered by Medicare. 
 
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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not show a clear cause of the enrollee's pain. Therefore, the reviewer found that the requested Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 5, 2023, to April 10, 
2023, billed with evaluation and management codes 99223-AI-25, 99232 (x3) and 99233. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the additional information requested has not been 
provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, the documentation submitted did not include the dates of service for each evaluation 
and management service. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on April 5, 2023, to April 10, 2023, billed with evaluation and management codes 99223-AI-25, 
99232 (x3) and 99233.