Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is an appropriate level of care for the 
enrollee. The Plan denied your request. The Plan says that records do not show that it is safe for the enrollee to 
leave the hospital. 
 
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. The enrollee 
is receiving appropriate care at the present acute care hospital. The does not enrollee require services at the 
LTACH that are not available at the acute care hospital where he/she is currently receiving care. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in 
the setting of lumbar stenosis and degenerative disc disease has 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept 
procedure is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage. 
 
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 the Intracept procedure for the enrollee.
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 you cannot live alone. The Plan denied your request. 
The Plan says needs can be met in a lower level of care, such as a skilled nursing facility. 
 
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 that the review indicates that the complexity of your nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance transport services (A0999) 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered. 
 
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 A0999 is "Unlisted ambulance service." 
 
We find that CPT code A0999 is not supported in the medical record. Specifically, this code is excluded from 
service. It is not clear what service this code is supposed to represent in this case. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for air ambulance transport services (A0999)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0239U) 
provided September 27, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria.  
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 0239U is targeted genomic sequence analysis panel, solid 
organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including 
substitutions, insertions, deletions, select rearrangements, and copy number variations. 
 
We find that CPT code 0239U is not supported in the medical record. Specifically, the claim was billed with a 
date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on 
September 16, 2021, rather than the billed date of service September 27, 2021. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided 
that the Plan does not have to pay for the targeted genomic sequence analysis panel (0239U) provided 
September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne testing (0037U) provided on March 16, 
2022. 
 
You asked the Plan to pay for FoundationOne testing. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, 
providers should enter the appropriate DEX Z-Code identifier adjacent to the Current Procedural Terminology 
(CPT) code in the comment/narrative field on the claim. 
 
We looked at the file and Medicare rules. A DEX Z-Code identifier was not reported on the claim for this 
Molecular Diagnostic Test service. Based on this information, we decided that Medicare rules for coverage of 
FoundationOne testing have not been met. Therefore, we decided that the Plan does not have to pay for 
FoundationOne testing (0037U) provided on March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 25, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481. 
 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 83789 
is a column II code to column I code G0481. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 83789 billed for date of service March 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan of extremity veins including responses to 
compression and other maneuvers; unilateral or limited study (code 93971) provided on March 1, 2022. 
 
You asked the Plan to pay for a duplex scan of extremity veins including responses to compression and other 
maneuvers; unilateral or limited study. The Plan denied your request. The Plan says this claim is a duplicate of 
a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 
 We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on March 23, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for a duplex scan of extremity veins including responses to 
compression and other maneuvers; unilateral or limited study have not been met. Therefore, we decided that 
the Plan does not have to pay for a duplex scan of extremity veins including responses to compression and 
other maneuvers; unilateral or limited study (code 93971) provided on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81455 provided on April 12, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on April 4, 2022. The date of service billed is April 12, 2022. This claim is not 
payable as billed. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
coded 81455 provided on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 15, 2022 billed with 
codes 81275, 81235, 81210, and 81276. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."] 
 
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 15, 2022 billed with codes 81275, 81235, 81210, and 81276.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that it is not safe for the enrollee to leave the hospital. 
 
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. The enrollee 
is presently receiving appropriate services in the short-term acute care setting. The provided records do not 
explain what care services will be provided in the LTACH that are not available in the present hospital setting. 
Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a 
lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled 
nursing facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
LTACH services. 
 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 81455 
provided on March 21, 2022. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like this 
claim reprocessed based on the medical records provided. The Plan denied your request. The Plan says code 
81455 is not covered as genetic testing procedures submitted with code 81455 are unlikely to impact 
therapeutic decision-making in the clinical management of the patient and will be denied automatically as not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that prior to April 1, 2022, Current Procedural 
Terminology (CPT) code 81455 was listed as a Group 3 code indicating it as a tier 1 Non-covered Codes for 
which genetic testing is unlikely to impact therapeutic decision-making in the clinical management of the 
patient. Subsequently, these codes will be denied automatically as not medically necessary. Based on this 
information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence 
analysis panel coded 81455 provided on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services (procedure code 0037U) provided to 
the enrollee on March 3, 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 unique identifier is missing. 
 
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 0037U is "Targeted genomic sequence analysis, solid 
organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number 
amplifications, gene rearrangements, microsatellite instability and tumor mutational burden." 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, it does not appear the 
unique identifier for this case was reported on the claim. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for genetic testing services (procedure code 0037U) provided to the enrollee on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing (81479) provided March 29, 2022. 
 
You asked the Plan to pay for the ConfirmMDx testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says coverage criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is covered for males with 
previous negative prostate biopsy who are being considered for repeat biopsy. 
 
We looked at the file and Medicare rules. The records do not contain results of a prior prostate biopsy. Based 
on this information, we decided that Medicare rules for coverage of ConfirmMDx testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing (81479) provided March 
29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37242 billed for date of service January 30, 
2022. 
 
You asked the Plan to pay for procedure code 37242. You say that the patient had the same procedure two days 
in a row. The medical records support payment of this code. The Plan denied your request. The Plan says 
procedure code 37242 is not supported in the medical record. A more accurate procedure should should be used 
to report this service. 
 
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 37242 is Vascular embolization or occlusion, inclusive of 
all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary 
to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial 
malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms). 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 37242. Our reviewer says that code 37242 is 
not supported in the medical record. Our reviewer found there is a more appropriate code that can be billed to 
capture the description of the procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 37242 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 37242 billed for date of service January 30, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on March 1, 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 that the services were not billed correctly. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan references Local Coverage Determination (LCD) L35025 and Local 
Coverage Article (LCA) A56853 in their determination; however, these rules are not binding for the state of 
Massachusetts where the testing was performed. The Plan has not provided any Medicare rules or 
documentation to support the services are not payable as billed. Therefore, we decided that the Plan has to pay 
for the laboratory services rendered on March 1, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on January 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that post-operative services and complications following 
surgery are included in the global surgery package. 
 
We looked at the file and Medicare rules. Procedure codes 14301, 15240, and 15004 were billed within the 90 
day global surgical period for procedure 14060 performed on December 9, 2021. Payment for these services is 
included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the 
surgical services rendered on January 26, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on May 17, 2022. 
 
You asked the Plan to pay for an emergency department visit. The Plan denied your request. The Plan says this 
claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on May 31, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for an emergency department visit have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
May 17, 2022.