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

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on July 19, 2022. 
 You asked the Plan to pay for definitive drug testing. You say that this test is covered by Medicare and was 
medically necessary. The Plan denied your request. The Plan says there is insufficient documentation to show 
that the requested number of drug classes was medically necessary and reasonable in this case. 
 
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 definitive drug testing have been met. 
Specifically, no medical records were provided to show that this test was ordered by the enrollees treating 
physician, and no results of a presumptive drug screening were provided to show that the criteria in the Local 
Coverage Determination have been met in this case. Therefore, we decided that the Plan does not have to pay 
for definitive drug testing (G0483) provided on July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records report you have chronic 
respiratory failure consequent to chronic obstructive pulmonary disease. The home ventilator is being requested 
for use in average volume assured pressure support (AVAPS) mode with auto-titration (AE) which could be 
provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a back-up rate.  As stated in 
the Local Coverage Determination (L33800): "Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied 
as not 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard hard appliance full arch (D9944). 
 
You asked the Plan to pre-approve the dental services. You say that that enrollee wore down their current night 
guard and is in need of a new one. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 13, 2021. 
Therefore, we decided that the Plan does not have to pre-approve an occlusal guard hard appliance full arch 
(D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that this is considered reasonable 
and necessary. The Plan denied your request. The Plan says this 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 proton beam radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while proton therapy is not an experimental therapy, any potential benefit 
or detriment of proton therapy over standard intensity modulated radiation therapy for routine cases is an 
investigational question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services coded 73502 provided on July 2, 2022. 
 
You asked the Plan to pay for x-ray services. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 73502 is not supported in the medical record. Specifically, this code was billed with 
modifier -76. The documentation shows that the repeat x-ray of the left hip and the x-ray readings were not 
done by the same physician. This means that the use of the -76 modifier is incorrect. Based on this information, 
we decided that Medicare rules for coverage of x-ray services have not been met. Therefore, we decided that 
the Plan does not have to pay for x-ray services coded 73502 provided on July 2, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (81292, 81294, 81295, 81297, 81298, 81300, 
81317, and 81319) provided on April 9, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this testing was necessary and should be paid. 
The Plan denied your request. The Plan says that the payment for these services is included in the payment to 
the facility where the enrollee was inpatient status. 
 
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. Specifically, the Plan has provided no evidence to support that the enrollee was 
inpatient status when the sample was taken or that these services have been paid to the hospital as part of the 
inpatient rate. Therefore, we decided that the Plan has to pay for laboratory services (81292, 81294, 81295, 
81297, 81298, 81300, 81317, and 81319) provided on April 9, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9374 billed for date of service October 30, 
2021 to November 12, 2021. 
 
You asked the Plan to pay for procedure code S9374. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9374 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9374 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9374 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9374 billed for date of service October 30, 2021 to November 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services that were 
recommended by their physician. The Plan denied your request. The Plan says the request 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you appear to still be unstable and require short-term additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer. You do 
not require services at the LTACH that are not already available at the current facility.  
 
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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neoadjuvant chemotherapy with Keytruda. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has stage I T1cNO triple 
negative breast cancer. The request is for neoadjuvant therapy with Keytruda. Keytruda is preferred for high-
risk triple negative breast cancer when used as part of a regimen for preoperative therapy with locally advanced 
c=T2 or cN+ and M0 disease, or cT1c, cN0 disease with pembrolizumab in combination with carboplatin and 
paclitaxel. The request is not supported by the Medicare-approved drug compendia and is not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve neoadjuvant chemotherapy with Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 5, 2021, to January 8, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
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 DRG 871. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, the documentation does not consistently and completely support the assigned principal 
diagnosis code and secondary diagnosis code with DRG. The replacement of DRG is upheld as it is supported 
by the medical documentation. The documentation does not indicate that the diagnostic work-up and treatment 
ordered by the treating medical providers supported a diagnosis code of A41.9 (Sepsis, unspecified organism) 
or R65.20 (severe sepsis without septic shock).  
 
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 to the enrollee from January 5, 2021, to January 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has a diagnosis of COPD. The enrollee was recently hospitalized for acute on chronic 
heart failure with reduced ejection fraction (HFrEF), with arterial blood gas (ABG) consistent with acute on 
chronic hypercarbic respiratory failure. However, the partial pressure of carbon dioxide (PaCO2) became 
normal with treatment of the heart failure, so the enrollee does not have chronic carbon dioxide (CO2) retention and does not meet criteria for ventilator support during sleep. If the enrollee did have chronic CO2 retention, 
bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) could be 
beneficial. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive hereditary pharmacogenomic testing and 
the hereditary genetic cardiac test panel provided on May 16, 2022.  
You asked the Plan to pay for the comprehensive hereditary pharmacogenomic testing and the hereditary 
genetic cardiac test panel. You say that you disagree with the Plan's denial. The Plan denied your request. The 
Plan says the services rendered are not a covered benefit. 
 
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 comprehensive hereditary pharmacogenomic testing and the hereditary 
genetic cardiac test 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 comprehensive 
hereditary pharmacogenomic testing and the hereditary genetic cardiac test panel provided on May 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Panzyga vial. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's provider has indicated that the requested intravenous immune 
globulin (IVIG) is being administered in the enrollee's home by a home health service. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
Medicare Part B pays for IVIG administered in the home only to treat a primary immune deficiency disease 
(congenital hypogammaglobulinemia, immunodeficiency with hyper-IgM, common variable 
immunodeficiency, Wiscott-Aldrich Syndrome, or combined immunity deficiency). IVIG administered/injected 
in the home for other diagnoses may be covered under part D.  
 IVIG for the enrollee's diagnosis can only be covered under Medicare Part B when the drug is being billed, 
dispensed and administered by the physician, physician-based infusion clinic or hospital-based infusion clinic. 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Panzyga vial.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth (D7240) and therapeutic 
parenteral drugs, two or more administrations (D9612). 
 
You asked the Plan to pre-approve the dental services. You say that you are scheduled for surgery next week 
and are requesting these services be approved. The Plan denied your request. The Plan says the requested 
dental procedure codes are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
removal of impacted tooth (D7240) and therapeutic parenteral drugs, two or more administrations (D9612).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine nucleic acid testing provided on July 14, 2022. 
 
You asked the Plan to pay for the urine nucleic acid testing. You say that the urine nucleic acid testing provided 
was medically necessary. The Plan denied your request. The Plan says the urine nucleic acid testing provided 
was 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 pay for the urine nucleic acid testing. Our reviewer 
says that the urine nucleic acid testing provided was not medically necessary. Our physician reviewer found 
Urine PCR amplification techniques raise considerable concerns regarding contamination from one specimen 
to another, creating the potential for false-positive results. The clinical interpretation of PCR results may also 
be challenging.  Amplification of organisms representing latent infection or colonization cannot be distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of 
nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally, 
specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large 
groups of patients for many of the microorganisms. 
 
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 urine nucleic acid testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine nucleic acid testing provided on July 14, 2022.