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

 
We decided that the Plan does not have to pre-approve the requested SiPortfolio biomarker testing. 
 You asked the Plan to pre-approve the siPortfolio testing. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says the requested testing is not intended to be used to diagnose MDS, and 
the genes requested for testing have not been adequately described. 
 
The Plan follows Medicare rules. Medicare rules say that oncology biomarker testing may be covered when the 
LCD guidelines are met. The rules also say that biomarker testing for MDS is used for prognostic purposes 
only.  
 
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 siPortfolio testing. Our reviewer 
says that the requested services are not shown to be medically reasonable and necessary based on the LCD 
guidance. Our physician reviewer found based on the medical records provided, there is no documentation that 
the siPortfolio testing at issue in this case meets all Medicare criteria for medically reasonable and necessary 
for the enrollee. Provided records in this case do not document that the enrollee has been diagnosed with 
myelodysplastic syndrome. Records indicate the testing has been ordered to rule out myelodysplastic 
syndrome. As stated in the relevant LCD, testing for myelodysplastic syndrome biomarkers is prognostic and 
not diagnostic. In addition, the provided records do not clarify exactly which biomarkers are being tested for 
and how the results would be used to treat the enrollee.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the siPortfolio testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the requested SiPortfolio biomarker testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 31, 2022, to 
June 7, 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 the 
medical records support the principal diagnosis A41.51. The Plan denied your request. The Plan says the 
medical records do not support the principal diagnosis A41.51. 
 
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 A41.51. 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 medical records do not support the principal diagnosis A41.51. Our physician reviewer found the 
enrollee presented with syncope and a urinary tract infection. The hospital appears to have coded for sepsis 
based on the discredited systemic inflammatory response syndrome (SIRS) criteria. The enrollee did not have 
any of the internationally recognized and validated sequential organ failure assessment (SOFA) criteria for 
sepsis. At presentation she had SIRS as might be expected for someone with syncope at presentation in the 
emergency department. Those criteria were not sustained and do not identify sepsis.  
 
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 May 31, 2022, to June 7, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for anesthesia for procedures on eye; lens surgery 
(code 00142) provided on November 30, 2022. 
 
You asked the Plan to waive the coinsurance for the anesthesia for procedures on eye; lens surgery. You say 
that you should not be responsible for two copayments for anesthesia services provided for the same eye 
surgery. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
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 
how much you should expect to pay for anesthesia services.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a 20% 
coinsurance for anesthesia services. The Plan contract does not clearly say how much enrollees must pay for 
anesthesia services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. Therefore, we decided that the Plan has to waive the coinsurance for anesthesia for procedures on 
eye; lens surgery (code 00142) provided on November 30, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99236 billed for date of service August 3, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 99236 is observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and medical decision 
making of high complexity. We asked our physician 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 billed services. Our reviewer found that the enrollee 
was evaluated for a malfunction of the dialysis catheter. The record supported that there was a comprehensive 
exam and medical decision making of high complexity. The records, however, did not support that there was a 
comprehensive history. Therefore, the billed code is not supported. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99236 billed for date of service August 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power arm brace (MyoPro) (L8702). 
 
You asked the Plan to pre-approve MyoPro. You say that this item is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of MyoPro orthotic device in the setting of 
upper extremity partial paralysis secondary to spinal cord injury have not been demonstrated in the peer-
reviewed literature. 
 
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 MyoPro. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this enrollees spinal cord condition or in widespread use for this enrollees condition based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this enrollee. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power arm brace (MyoPro) (L8702).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiography (93306). 
 
You asked the Plan to pre-approve a transthoracic echocardiography. The Plan denied your request. The Plan 
says that this request is not medically necessary per Medicare rules. 
 
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 a transthoracic echocardiography. Our 
reviewer says that a transthoracic echocardiography is considered medically reasonable and necessary in this 
case. Our physician reviewer found an individual with multi-level valvular heat disease, Bioprosthetic Mitral 
valve and Tricuspid annuloplasty, with a reported transesophageal echocardiogram (TEE) in 2019, benefits 
from periodic transthoracic echocardiogram for management of valvular heart disease. 
 
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 transthoracic echocardiography have been met. Therefore, we decided that the 
Plan has to pre-approve a transthoracic echocardiography (93306).  
 
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: Favorable

 
We decided that the Plan has to pay for the supplies (procedure code A4595) rendered on September 20, 2022. 
 
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. 
The Plan says that there is evidence of misrepresented services. 
 
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. 
 
The plan's denial is invalid, as the case file contains a proof of delivery and packing slip for supplies packed on 
September 20, 2022 and delivered on September 27, 2022. Based on this information, we decided that 
Medicare rules for coverage of the supplies have been met. Therefore, we decided that the Plan has to pay for 
the supplies (procedure code A4595) rendered on September 20, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 5, 
2022, to November 6, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the 
inpatient care was 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 that the enrollee was admitted in stable condition with a diagnosis of transient 
ischaemic attack (TIA), and there was not a reasonable expectation that the care would need to span 2 or more 
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 from November 5, 2022, to November 
6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman device. 
 
You asked the Plan to pre-approve the Minuteman device. You say that the Minuteman device is medically 
necessary. The Plan denied your request. The Plan says the Minuteman device 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 the Minuteman device. Our reviewer 
says that the Minuteman device is not medically necessary. Our physician reviewer found the Minuteman 
device is experimental. More research is needed 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 the Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Minuteman device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services rendered from February 13, 2022, to 
March 1, 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 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 14, 2022. The NOA was not received by the Plan until October 26, 
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 rendered 
from February 13, 2022, to March 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on 
November 30, 2021, as billed with rate code KBKE1. 
 
You asked the Plan to pay for SNF services at the original rate code billed. You say that these services are 
supported in the medical record and were reported correctly. The Plan denied your request. The Plan says the 
medical records provided do not support the rate code billed in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report SNF services with the appropriate HIPPS code. 
 
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 SNF services at the original rate code billed. 
Our reviewer says that the documentation does not support that the PDPM submitted by the skilled nursing 
facility was correct. Our physician reviewer found the documentation available for review does not support that 
the enrollee received or required a mechanically altered diet. The 2nd alphanumeric character in the PDPM was 
not correct. The partial adjustment to PDPM KAKE1 was appropriate. 
 
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 services at the original rate code billed have not been met. Therefore, we 
decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on November 30, 
2021, as billed with rate code KBKE1.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the left total knee replacement (27447). 
 
You asked the Plan to pre-approve the surgical procedure. You say that say the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says based on this 
information, you are asking for reconsideration of the previous decision and allow coverage for the procedure 
the doctor has requested. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documented recent 6-week trial of physical therapy for knee pain. More 
conservative measures needed. The criteria have not been met.  
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the left total knee replacement (27447).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) and segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667) to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and full leg segmental pneumatic appliance to be 
provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan 
says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not 
been met. 
 
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 requested provider in this case is not a network provider with the Plan. 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 items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor (E0652) and segmental pneumatic appliance for use with pneumatic compressor, full 
leg (E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 13, 2021, by an out-of-
network (OON) provider. 
 
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 this out-of-network service was not pre-approved or 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 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 services at issue in this appeal. The Plan did not pre-approve the service 
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 lab services provided on December 13, 2021, by an out-of-network 
(OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says you have no daily skilled nurse or therapist needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.