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. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient 
basis. 
 
 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.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice services provided on January 9, to January 31, 2022. 
 
You asked the Plan to pay for hospice services. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospice services provided on January 9, to January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dialysis procedure to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a dialysis procedure. You say that you have been receiving care from this 
facility for a year and it is close to your residence. The Plan denied your request. The Plan says the services 
have been requested from an out-of-network provider. The Plan has in-network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a dialysis procedure to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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. 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 services are not medically necessary. Our physician reviewer found you have a history of low back pain. 
The requested Vertiflex spacer is considered experimental in nature, as more research is needed to show its 
safety and efficacy. The services are therefore not reasonable or medically 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 these services have not been met.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nebulizer supplies (J7606, J7613, J7626) provided on 
October 19, 2021. 
 
You asked the Plan to pay for nebulizer supplies. You say that the nebulizer supplies at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have 
not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document provided as proof of delivery does not specify that it pertains to the supplies at issue. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for nebulizer supplies (J7606, J7613, J7626) provided on 
October 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on June 28, 2021, through 
February 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy services. You say that you had treatment with a plan contract 
provider but was not successful. The Plan denied your request. The Plan says services were not authorized by 
network/primary care provider. 
 
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 psychotherapy services at issue in this appeal. The Plan did not pre-
approve the psychotherapy services 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 psychotherapy services 
provided on June 28, 2021, through February 28, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (20930, 22853, 69990) provided September 
2, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the billed codes cannot be paid.  
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 20930 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 20930 is not separately payable. Codes 69990 and 22853 have bundled relationships with other codes 
billed and were not billed with modifiers to bypass the edit. Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (20930, 22853, 69990) provided September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on December 23, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene. 
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing provided on 
December 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on January 26, 2022. 
 
You asked the Plan to pay for CT of the head or brain. You say that this claim was billed with an appropriate 
Place of Service (POS) code. The Plan denied your request. The Plan says the enrollee was inpatient status on 
the date of these services, and therefore this claim was billed with an inappropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that when a patient is registered inpatient status, POS code 21 should be used regardless of 
the setting where services took place. 
We find that CPT code 70450 is not supported in the medical record. Specifically, this claim was billed with POS code 22 (On Campus  Outpatient Hospital); however, the record shows that the enrollee was inpatient 
status on the date in question. This means that POS code 21 is appropriate in this case. Based on this 
information, we decided that Medicare rules for coverage of CT of the head or brain have not been met. 
Therefore, we decided that the Plan does not have to pay for computed tomography (CT) of the head or brain 
(70450) provided on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 29, 2021. 
 
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 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 April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar orthosis provided on February 11, 2022. 
 
You asked the Plan to pay for the services provided. You say that you do not agree with the decision. The Plan 
denied your request. The Plan says a face-to-face exam was not provided. The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation.  
 
We looked at the file and Medicare rules. The medical records provided show the enrollee was treated for a 
productive cough and sore throat. The records also noted the enrollee was sitting in a wheelchair at the time of 
visit. The records do not include previous physical exams, testing, or imaging to confirm a diagnosis or 
condition that would warrant a lumbar orthosis. The records do not include a treatment plan that involves a 
lumbar orthosis. Based on this information, we decided that the Medicare rules for coverage have not been met.  
Therefore, we decided that the Plan does not have to pay for the lumbar orthosis provided on February 11, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 genetic testing services performed on February 
15, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment based on the medical records. The Plan denied your request. The Plan says the 
criteria for coverage have not been satisfied in this case. 
 
The Plan follows Medicare rules. Medicare rules say that Guardant360 is subject to the criteria listed 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 pay for the genetic testing services. Our reviewer 
says that the ordered test was not medically reasonable and necessary. Our physician reviewer found the 
enrollee has a diagnosis of Malignant neoplasm of unspecified part of right bronchus or lung (Stage IIIA Non-
small cell lung adenocarcinoma). A fine needle cytology report dated January 25, 2022, documents metastatic 
adenocarcinoma. In this case, the documentation does not support that tissue-based, comprehensive genomic 
profiling is infeasible or has shown no actionable mutations as required by the Medicare coverage criteria. 
 
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 genetic testing services have not been met. Therefore, we decided that the 
Plan does not have to pay for Guardant360 genetic testing services performed on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 20, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on December 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision of trochanteric bursa for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the recent magnetic resonance imaging (MRI) of the right hip failed to show severe 
bursitis, and instead revealed tendinosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the diagnosis of trochanteric bursitis is not confirmed by magnetic resonance imaging (MRI). 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve excision of trochanteric bursa for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 10, 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 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 January 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 15, 
2021. 
 
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 denied procedure code was not billed with the required device. 
 
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 27486 is "Revision of total knee arthroplasty, with or 
without allograft; 1 component." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that detailed documentation is not 
evident regarding any components of the total knee having been revised. The exam demonstrated that there was 
a large defect of the superior medial aspect of the patella and also more proximally into the quadriceps tendon 
could be palpated. Incision was made and then a medial arthrotomy was performed.  This was next to the firm area of the quadriceps that could feel that was clearly subluxing laterally. A medial 
release was performed for visualization. Prepatellar fat was excised. Synovectomy was performed of the 
superior and inferior aspects of the medial and lateral gutters. The vastus medialis was elevated over the fascial 
layer. The vastus medialis was mobilized by performing an extensive dissection. Some soft tissue around the 
patellar button was excised. There was no indication of revision of 1 component of the total knee joint. 
Therefore, the records do not support CPT 27486- Revision of total knee arthroplasty, with or without allograft, 
1 component. 
 
We looked at this coder'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 surgical services provided to the enrollee on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 18, 2022. 
 
You asked the Plan to pay for an office visit. You say that you do not believe you should be responsible for the 
costs associated with the service provided other than the co-pay. The Plan denied your request. The Plan says 
the out-of-network service was not authorized. 
 
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 an office visit provided on February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement prosthetic leg (L5910, L5981) for the 
enrollee. 
 
You asked the Plan to pre-approve the leg. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request exceeds medical need. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the leg. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested items exceed the patient's medical need as the treating nurse 
practitioner  documentation does not support that the patient has irreparable wear or damage or is unable to use 
the alignable system or current foot that he currently has. The treating nurse practitioner documentation does 
not confirm the patient is a K3 level ambulator. 
 
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 leg have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a replacement prosthetic leg (L5910, L5981) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided on November 8, 2021. 
 
You asked the Plan to pay for paramedic intercept. You say that this ambulance transportation was medically 
necessary and should be paid in full. The Plan denied your request. The Plan says the rules for coverage of 
paramedic intercept services are not met in this case. Please note that the claim for ambulance transportation 
was provided by and paid in full to a separate company who provided the actual transport. The services at issue 
are paramedic intercept services which are not payable in this case. 
 The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided on November 8, 2021.