Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item serves the same purpose as an item already provided to you. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a group 3 custom power wheelchair. A group 3 custom power wheelchair serves 
the same purpose as a power scooter. Therefore, we decided that the Plan does not have to pre-approve a power 
scooter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab, Docetaxel and Ramucirumab. 
 
You asked the Plan to pre-approve Pembrolizumab, Docetaxel and Ramucirumab. 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 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 Pembrolizumab, Docetaxel and 
Ramucirumab. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
in this case, the record indicates that the enrollee has a diagnosis of metastatic non-small cell carcinoma. The 
Food and Drug Administration has not stated that the requested drug regimen is indicated for the enrollee's 
condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of 
the requested drug regimen in the enrollee's clinical situation. No literature from Medicare approved cancer 
journals were submitted for review. The elements of the coverage criteria are not satisfied. The requested 
service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pembrolizumab, Docetaxel and Ramucirumab have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Pembrolizumab, Docetaxel and Ramucirumab.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 17, 2022, billed with 
codes 81206, 81210, 87235, 81275, 87276, 87292, 81295, 81298, 81301, 81317, 81401, 81194, and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that the medical records support the necessity 
of this testing. The Plan denied your request. The Plan says panel testing should be billed using one CPT code 
on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 17, 2022, billed with codes 81206, 81210, 87235, 81275, 87276, 87292, 81295, 81298, 81301, 81317, 
81401, 81194, and 81309.
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 
August 12, 2021, to August 19, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
medically necessary. 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 252. 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 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 I50.21 (Acute systolic (congestive) Heart failure). 
  
 
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 August 12, 2021, to August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (cutaneous squamous cell carcinoma) 
(DecisionDx-SCC) (0315U) provided July 11, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC. You say that you are requesting the DecisionDx-SCC test 
be reprocessed and approved the Medicare established rate of $3873.00. The Plan denied your request. The 
Plan says the DecisionDx-SCC is experimental and investigational and is not considered the standard of care 
for determining treatment of squamous cell carcinoma. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC have not been met. Therefore, we decided that the Plan does not have to pay 
for oncology (cutaneous squamous cell carcinoma) (DecisionDx-SCC) (0315U) provided July 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 12, 2022, billed with 
codes 81225, 81226. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 12, 2022, billed with codes 81225, 81226.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polymerase chain reaction (PCR) nail panel testing (87481, 
87640, 87653, 87651, 87801 & 87798) provided on March 29, 2022. 
 
You asked the Plan to pay for PCR nail panel testing. You say that the PCR testing was medically necessary. 
The Plan denied your request. The Plan says the testing is not medically necessary as the requested testing 
exceeds the member's medical needs. 
 
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 PCR nail panel testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that PCR testing for the diagnosis of onychomycosis is experimental/investigational. 
There is insufficient scientific evidence in the current medical literature to indicate that this technology is as 
beneficial as the established alternatives. The review has determined that the items/services at issue in this case 
are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PCR nail panel testing have not been met. Therefore, we decided that the Plan 
does not have to pay for polymerase chain reaction (PCR) nail panel testing (87481, 87640, 87653, 87651, 
87801 & 87798) provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient home visit rendered on August 10, 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 procedure code 99343 is not supported. 
 
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 99343 is home visit for the evaluation and management 
of a new patient. 
 
We find that CPT code 99343 is not supported in the medical record. Specifically, the file shows that 
evaluation and management codes 99307 and 99308 were billed for this enrollee within the last year; therefore, 
a new patient visit does not apply. 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 pay for the new patient 
home visit rendered on August 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram rendered on January 27, 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 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 items/services at issue were 
reimbursed by the Plan on February 1, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the mammogram rendered on January 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital clinic visit (G0463) destruction 
(eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, 
actinic keratoses); first lesion  (17000) destruction (eg, laser surgery, electrosurgery, cryosurgery, 
chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, 
each (list separately in addition to code for first lesion) (17003) tangential biopsy of skin, single lesion (11102) 
tangential biopsy of skin, each separate/additional lesion (List separately in addition to code for primary 
procedure) (11103) provided September 15, 2022. 
 
You asked the Plan to waive the copayment for the outpatient surgical visit. You say that during this time you 
had to change Plans. Please review and see if this was paid correctly under the new coverage. The Plan denied 
your request. The Plan says 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 clearly says that you must pay $325 
copayment for in-network surgery services in an outpatient hospital.  
 
You have been asked to pay $175.72 for the outpatient surgical visit. Since the allowed amount of $175.72 is 
less than the copayment amount of $325.00, you are responsible for the lesser amount. This item/service falls 
within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the hospital clinic visit 
(G0463) destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), 
premalignant lesions (eg, actinic keratoses); first lesion  (17000) destruction (eg, laser surgery, electrosurgery, 
cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 
14 lesions, each (list separately in addition to code for first lesion) (17003) tangential biopsy of skin, single 
lesion (11102) tangential biopsy of skin, each separate/additional lesion (List separately in addition to code for 
primary procedure) (11103) provided September 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis, abduction positioning, 
airplane design, prefabricated, includes fitting and adjustment provided to the enrollee on August 3, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation submitted did not sufficiently support the billed supply code. 
 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the the documentation doesn't clearly indicate the need for the requested orthosis of the left upper 
extremity. The enrollee has what is described as isolated shoulder pain and there is no physical exam to 
indicate the joint is unstable or requires an orthosis. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a shoulder elbow wrist hand orthosis, abduction positioning, airplane design, prefabricated, 
includes fitting and adjustment provided to the enrollee on August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308 billed for date of service June 13, 
2022. 
 
You asked the Plan to pay for procedure code 99308. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 99308 is bundled into 
payment for code 99316. 
 
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 99308 
is a column II code to column I code 99316 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99308 billed for date of service June 13, 2022.
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 are requesting the need for physicians on site 
that can frequently monitor your condition to monitor your healing. The Plan denied your request. The Plan 
says the notes do not show that you must have an intensive therapy program to improve self-care functioning. 
Your medical and therapy needs could safely be met in a skilled nursing unit. 
 
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 medically necessary care can be provided safely in a different level of care. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter implantation (CardioMEMS) of wireless 
pulmonary artery pressure sensor for long-term hemodynamic monitoring (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the CardioMEMS device will allow 
the enrollee a better monitor and manage those symptoms that lead to repeated heart failure hospitalizations. 
The Plan denied your request. The Plan says the requested device remains of uncertain value in the most recent 
AHA/ACC Heart Failure Guidelines. It is not medically necessary for this enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor 
device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management 
of enrollees with CHF. The clinical study on which FDA approval was based showed improved clinical 
outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was implanted, 
reflecting an enrollee population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with 
the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this enrollee's clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transcatheter implantation (CardioMEMS) of wireless pulmonary artery 
pressure sensor for long-term hemodynamic monitoring (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it seems as though IGRT is simply being used as routine practice, as there does not seem to be 
any exceptional circumstances with this enrollee necessitating the need for IGRT. The request is unfavorable as 
IGRT is not an accepted standard of care for routine use in the palliative treatment of bone metastases. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guided Radiation Therapy (IGRT).