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

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) (93702) 
(ImpediMed L-Dex device). 
 
You asked the Plan to pre-approve an ImpediMed L-Dex device. You say that you believe the use of 
ImpediMed's L-Dex device is medically necessary for the enrollee. The Plan denied your request. The Plan 
says the use of bioimpedance spectroscopy for lymphedema is unproven and not medically necessary due to 
insufficient evidence of safety and/or efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an ImpediMed L-Dex device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the ImpediMed L-Dex device was requested for this enrollee to screen for 
possible lymphedema. Our reviewer found that this device has insufficient high-quality evidence to support its 
regular use is superior to standard screening methods in terms of overall long-term outcomes. Our physician 
reviewer also found that without sufficient support made for this request, the ImpediMed L-Dex testing will be 
considered not medically 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 an ImpediMed L-Dex device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) (93702) (ImpediMed L-Dex device).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says there is 
insufficient documentation to corroborate the services. 
 
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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The records do not show that the 
testing of 22 or more drug classes were ordered or provided. 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 G0483 billed for date of service June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on May 15, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
services provided on May 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve a continuation of SNF care. You say that the enrollee needs more time. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
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 a continuation of 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 that 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 
have 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 
SNF setting. Records do not support that services in the home with home health care or in a long-term care 
facility on a part time basis are not appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuation of SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
March 23, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an approved test which was provided for a 
covered indication. 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 F1CDx testing have 
not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) 
(0037U) testing provided on March 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service February 7, 
2022. 
 
You asked the Plan to pay for procedure code 99072. The Plan denied your request. The Plan says procedure 
code 99072 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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service February 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CMF Spinalogic bone growth stimulator from an out-
of-network (OON) provider. 
 
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 available from network providers. 
 
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 these services. Our reviewer says that the out-of-network services are not 
medically necessary. Our physician reviewer found the records do not document any unique characteristics or 
device features that necessitate the specific CMF Spinalogic bone growth stimulator over the standard device 
from the network provider. The services from the out-of-network provider are 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.  
 
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 these services. Therefore, we decided that the Plan 
does not have to pre-approve a CMF Spinalogic bone growth stimulator from an out-of-network (OON) 
provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a capsule endoscopy (91110). 
 
You asked the Plan to pre-approve capsule endoscopy. You say that this service is being requested to rule out 
small bowel Crohn's disease in addition to additional angiectasias of the small bowel. You also say that this is 
medically necessary. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that capsule endoscopy is covered for those who have had 
upper and lower GI endoscopies within the past 12 months (esophagogastroduodenoscopy (EGD) and 
colonoscopy) that have failed to identify a bleeding source. 
 
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 capsule endoscopy. Our reviewer says 
that the requested capsule endoscopy is not medically necessary. Our physician reviewer found the provided 
documentation does not support that the enrollee has an iron deficiency. The reviewer found that the 
documentation indicates bleeding sites were found and treated endoscopically. The reviewer found that both an 
esophagogastroduodenoscopy (EGD) and colonoscopy have been performed within 6 months, and small bowel 
series identified no pathology. Therefore, the reviewer found that the requested capsule endoscopy is not 
medically reasonable or 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 capsule endoscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a capsule endoscopy (91110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health visit provided to the enrollee on January 5, 2022, by an out-of-network (OON) provider.
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain the authorization and you would like the claim reprocessed for payment. The Plan denied your request. The Plan says that there was no approved authorization for these services.
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 the home health visit provided to the enrollee on January 5, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (excludes sacral nerve), Sprint Neurostimulator (CPT code 64555 X 2). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Sprint system has no trial nerve stimulation and is a temporary, non-permanent 
device. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure for right shoulder pain is the subject of ongoing clinical trials (e.g. 
NCT03752619). The enrollee is not enrolled in a clinical trial. 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator electrode array; peripheral nerve 
(excludes sacral nerve), Sprint Neurostimulator (CPT code 64555 X 2).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from March 
15, 2022, to April 13, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says 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 March 15, 2022. However, the admit date submitted on the claim is December 15, 2021, which is not correct. Therefore, we decided that the Plan does not have to pay for home 
health services provided to the enrollee from March 15, 2022, to April 13, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 10, 
2022. 
 
You asked the Plan to pay for procedure code 99285. The Plan denied your request. The Plan says payment for 
code 99285 is bundled into payment for code 99220.  
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 99285 
is a column II code to column I code 99220. 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 99285 billed for date of service January 10, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services (99190, 99190-76, 99191, 99192, 86891 
and P9022) provided on June 14, 2022. 
 
You asked the Plan to pay for hospital services. You say that these services were reported correctly and should 
be paid. The Plan denied your request. The Plan says the payment for these services may only be furnished 
directly to the hospital facility. 
 
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
We looked at the file and Medicare rules. Although these services may be appropriate, payment for them is 
made to the hospital which must then furnish these services either directly or under arrangements. As such, 
separate Medicare payment cannot be made for the services at issue. Based on this information, we decided that 
Medicare rules for coverage of hospital services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services (99190, 99190-76, 99191, 99192, 86891 and P9022) provided on June 14, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair repairs. 
 
You asked the Plan to pre-approve the wheelchair repairs. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 
 
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 wheelchair repairs have been met. 
Because the condition of the current chair is not documented, the submitted records are not sufficient to 
determine that the requested repairs are necessary to make the equipment serviceable. Therefore, we decided 
that the Plan does not have to pre-approve the wheelchair repairs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cough assistance device. 
 
You asked the Plan to pre-approve a cough assistance device. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that mechanical in-exsufflation devices (E0482) are 
covered for beneficiaries who meet specific criteria. 
 
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 cough assistance device. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the LCD criteria require the 
patient to have a neuromuscular disorder to justify use/coverage of this device. This enrollee does not have a 
formal neuromuscular disorder directly causing the difficulty clearing secretions according to the provided documentation. Therefore, the Synclara device will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a cough assistance device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a cough assistance device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 19, 2022 to 
January 22, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the Plan's suggested change and contend that the diagnosis is supported. The Plan denied your 
request. The Plan says even though J96.01 is coded on the claim, the documentation received was 
inconsistent/unclear regarding this diagnosis and supporting medical record documentation was unable to be 
found. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code, J96.01, defined as Acute respiratory 
failure with hypoxia. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the submitted DRG is not supported. Our 
physician reviewer found the billing of acute respiratory failure with hypoxia is not supported. Our reviewer 
found that the medical records do not support the DRG 190. Our physician reviewer also found that the DRG 
191 would have been more appropriate for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 19, 2022 to January 22, 2022, at the Diagnosis Related 
Group (DRG) originally billed.