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

 
We decided that the Plan does not have to pay for hereditary breast cancer-related disorders; genomic sequence 
analysis panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, 
MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53 (81432) and hereditary breast cancer-related 
disorders; duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and 
STK11 (81433), 
 You asked the Plan to pay for the genetic testing. You say that this testing is necessary to choose the most 
appropriate course of treatment and/or surveillance. The Plan denied your request. The Plan says the enrollee 
does not qualify for this testing because the records do not show a personal history of breast, ovarian, 
pancreatic or prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA1 and BRCA2 testing may be covered for 
individual who have, or have a personal history of ovarian, breast, prostate, pancreatic or metastatic prostate 
cancer. 
 
We looked at the file and Medicare rules. In this case the records do not show that the enrollee has a personal 
history of ovarian breast, prostate or pancreatic cancer. Based on this information, we decided that Medicare 
rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have 
to pay for hereditary breast cancer-related disorders; genomic sequence analysis panel, must include 
sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, 
PTEN, STK11, and TP53 (81432) and hereditary breast cancer-related disorders; duplication/deletion analysis 
panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11 (81433),
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 the member is receiving appropriate in-patient acute care and 
is currently unstable for transfer to an LTACH. 
 
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 
documentation does not support that the member has need for complex medical treatment. The member does 
not require services at the LTACH that are not available at the acute care hospital or the skilled nursing facility. 
The requested treatments are not medically necessary at the LTACH level of care. The member has stabilized 
medically and can receive further care at the current acute care hospital or a lower level of care when deemed 
appropriate. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the request for a home mechanical ventilator set in TTV-VAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary. You were recently hospitalized with acute 
hypercarbic respiratory failure requiring mechanical ventilation, with a diagnosis of COPD and severe obesity. 
There is no documentation of chronic CO2 retention on arterial blood gas while stable as an outpatient. 
Medicare does not cover a home ventilator when used as BiPAP. Our physician reviewer found that your condition does not meet Medicare criteria for a home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on December 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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 has not provided any evidence that the specimen was not obtained in 
the Independent or Reference Laboratory. There are no records that show the specimen was collected 
elsewhere. Therefore, we decided that the Plan has to pay for the laboratory services provided on December 28, 
2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 8, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on February 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0856, 
E2300, E2361, E1028, E2310, E0973, K0040, E0995, E2607). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee is at risk for 
decline in independence, withdrawal from activities, poor positioning, decline in quality of life and social 
isolation. The Plan denied your request. The Plan says the enrollee does not have a medical need for a group 3 
power wheelchair with the requested power option(s)/feature(s). 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a 
neurologic disorder with functional deficits. Criteria for a power wheelchair are met. The documentation does 
not indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the bladder that 
would necessitate power tilt or recline. The requested electrical accessories are not medically necessary as she 
does have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. As she does not have need for multiple power accessories, the requested 
group 3 power wheelchair is not medically necessary as the enrollee's needs can be met with a different power 
wheelchair. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0856, E2300, E2361, 
E1028, E2310, E0973, K0040, E0995, E2607).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76983 billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for procedure code 76983. You say that these services were billed correctly and 
should receive separate payment. The Plan denied your request. The Plan says payment for code 76983 is 
bundled into payment for code 76641. 
 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 76983 
is a column II code to column I code 76641. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76983 billed for date of service April 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81286, 81413, 81414, 
81442, 81161 and 81479 provided November 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that lab does not require active medical/state 
license and your lab is operating within Texas The Plan denied your request. The Plan says unable to verify 
provider's license. 
 
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 the laboratory services coded as 
81286, 81413, 81414, 81442, 81161 and 81479 provided November 16, 2021 have been met. The Plan made 
multiple attempts to obtain supporting medical records from the provider without success. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded as 81286, 81413, 81414, 81442, 
81161 and 81479 provided November 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of long term 
acute care admission. The Plan denied your request. The Plan says admission to LTACH was denied as not 
meeting criteria, is not medically necessary, and continued acute hospital stay was offered, until you could 
discharge to a lower level of care. 
 
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 you were admitted to the current acute care hospital with acute respiratory failure, 
acute on chronic heart failure, acute kidney injury, and urinary tract infection requiring antibiotics, diuresis, 
dobutamine, bi-level positive airway pressure (BiPAP), oxygen support and vasopressors. Recent notes 
describe you as having completed antibiotics, requiring basic wound care for sacral wound, and still dependent 
on BiPAP and high flow oxygen support.  
 You appear to be still somewhat unstable and require additional acute care services that can safely be 
administered at the current facility until more stable and appropriate for a lower level of care. 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 the LTACH services.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the medical criteria needed for an IRF admission have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is not a reasonable expectation that this patient 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the heart (75571). 
 
You asked the Plan to pre-approve a CT of the heart. You say that your doctor said you need this test, and you 
feel it must be needed to ensure your heart is functioning properly. The Plan denied your request. The Plan says 
that Medicare does not cover the requested study for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT of the heart. Our reviewer says 
that a CT of the heart is reasonable and necessary. Our physician reviewer found while you have no clinical 
signs of coronary insufficiency, you do have both aortic and mitral valvular disease. In particular, the aortic 
valvular disease is associated with increased risk of coronary disease. Our reviewer also found that due to the 
documented valvular heart disease, the requested CT coronary calcium scoring should be approved. 
 
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 CT of the heart have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) of the heart (75571).  
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member's care needs can continue to be met in the skilled nursing 
facility setting. 
 
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. The complexity of the patients nursing medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require the intensity of 
rehabilitation physician oversight provided in the acute inpatient rehabilitation setting. She does not require 
rehabilitation nursing for complex wound care, parenteral nutrition or tube feedings, tracheostomy management 
or bowel and bladder management. Her medical and rehabilitation needs do not require the intensive 
interdisciplinary approach provided on acute inpatient rehabilitation. The patient does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program at least three hours a day and five days a week, or 15 hours over seven consecutive days. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on February 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for domiciliary services provided on February 23, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a facet joint ablation procedure (64635, 64636). 
 
You asked the Plan to pre-approve the facet joint ablation procedure. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says that coverage rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no more than two procedures per section of the spine 
will be covered in a calendar year. 
 
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 facet joint ablation procedure. Our 
reviewer says that the requested procedure is medically necessary. Our physician reviewer found it has been 
more than 12 months since the previous procedure. The requested procedure is medically necessary and 
coverage rules are 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 facet joint ablation procedure have been met. Therefore, we decided that the 
Plan has to pre-approve a facet joint ablation procedure (64635, 64636).  
 
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 pre-approve Allograft ViviGen. 
 
You asked the Plan to pre-approve Allograft ViviGen. You say that the enrollee does not have the best quality 
bone and will need the best opportunity to have successful fusion. You say that the osteoblast cells in the 
ViviGen will allow accelerated and more robust fusion at the disc service and reduce the risk of 
pseudoarthrosis. The Plan denied your request. The Plan says the Allograft ViviGen is not medically necessary 
due to insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Allograft ViviGen. Our reviewer says 
that Allograft ViviGen is not considered medically reasonable and necessary in this case. Our physician 
reviewer found Allograft ViviGen is experimental. More research is needed. Iliac crest autograft is the gold 
standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Allograft ViviGen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Allograft ViviGen.