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

 
We decided that the Plan has to pay for drug testing provided on August 8, 2018. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service 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. In this case, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT code 
80307 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record 
indicates that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate 
for the Plan to deny these services based on the physician signature. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay 
for drug testing provided on August 8, 2018.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the LTACH services 
based on the medical necessity needs of the enrollee and the enrollee meeting the LTACH criteria. The Plan 
denied your request. The Plan says the enrollee's needs can be met at an alternate level of care such as a skilled 
nursing facility. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  
 
  There are no services available at the LTACH that the enrollee requires 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 the diagnosis and 
condition of the enrollee 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 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 IRF admission is necessary to continue progress and 
to return to the prior level of function. The Plan denied your request. The Plan says you do not meet the rules 
for IRF admission. The Plan says there is evidence in the medical record that you would not be able to tolerate 
an intensive rehabilitation program. The Plan also says that your needs can be met at a lower level of care such 
as a Skilled Nursing Facility (SNF). The Plan says SNF was offered and would be authorized if requested 
within 24 hours. No action was taken to request the SNF services.  
 
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 the complexity of your nursing, medical, and rehabilitation needs does not require 
IRF admission. You were admitted to the hospital for pneumonia and pulmonary embolism. Your medical 
problems are now stable and you do not have complex nursing or rehabilitation needs. Our reviewer also found 
that the medical record indicates you may have a need for physical and/or occupational therapies, but there is 
no documentation supporting the need for these services to be provided in an intensive rehabilitation program. 
Our reviewer says there is no reasonable expectation that you will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program offered in an IRF. You can receive medically necessary care 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the addition, endoskeletal, knee-shin system, stance flexion 
feature, adjustable (L5845). 
 
You asked the Plan to pre-approve the knee-shin stance flexion feature. You say that the medical records 
provided support the necessity of the service in dispute. The Plan denied your request. The Plan says that the 
components involving the additional knee-shin stance flexion feature is not reasonable and necessary for the 
approved prosthesis. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the knee-shin stance flexion feature. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is noted to have the potential to be a K-3 level ambulator. 
Therefore, he would qualify for an addition code for the endoskeletal knee shin system. While the knee shin 
stance flexion feature (L5845) is not listed in the policy, it does appear to be comparable in terms of offering 
swing phase control by means of a mechanical extension assist. This appears to be a code specific to the make 
of the prosthetic knee joint requested. Therefore, the requested knee shin stance flexion feature (L5845) can be 
considered 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 the knee-shin stance flexion feature have been met. Therefore, we decided that 
the Plan has to pre-approve the addition, endoskeletal, knee-shin system, stance flexion feature, adjustable 
(L5845).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve the hospital bed. You say that you are appealing the denial of the requested 
semi-electric hospital bed as you feel that it is medically necessary. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria for approval for the semi electric hospital bed 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or  
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 hospital bed. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that the enrollee has a condition that requires frequent 
positioning of the bed and mattress to alleviate pain, promote good body alignment, prevent contractures, or 
avoid respiratory infections in a way that an ordinary bed is not able to. 
 
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 hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve semi-electric hospital bed (E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this ventilator is medically reasonable for 
your condition. The Plan denied your request. The Plan says the criteria for a ventilator have not been satisfied. 
 
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 the requested home ventilator is not medically reasonable and necessary. Our physician reviewer found the 
record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. 
The provided primary source documentation does not contain sufficient detailed information in the medical 
record to justify the treatment selected. You could be treated with a bilevel positive airway pressure machine 
with average volume-assured pressure support capability. The Plan has indicated coverage for such a device is available upon request. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the deep sedation/general anesthesia-first 
15 minutes (D9222), deep sedation/general anesthesia, each subsequent 15 minute increment (D9223), the 
extractions, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x 2), limited oral 
evaluation (D0140), panoramic radiographic image (D0330), and the therapeutic parenteral drug, single 
administration (D9610) provided on November 11, 2021. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services at 
issue were rendered by a provider that has opted out of the Medicare program; therefore, the services are not 
payable. 
  
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this case were provided in a non-urgent, non-emergent situation by a provider who has 
opted out of the Medicare program. Therefore, we decided that the Plan does not have to issue reimbursement 
for the deep sedation/general anesthesia-first 15 minutes (D9222), deep sedation/general anesthesia, each 
subsequent 15 minute increment (D9223), the extractions, of an erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210 x 2), limited oral evaluation (D0140), panoramic radiographic image (D0330), and 
the therapeutic parenteral drug, single administration (D9610) provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents (D4381 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says localized delivery of antimicrobial agents is not listed as a covered 
service. 
 
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 localized delivery of 
antimicrobial agents are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve localized delivery of antimicrobial agents (D4381 x 4).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need to be at the skilled nursing facility 
(SNF). The Plan denied your request. The Plan says based on Medicare guidelines, the Skilled Nursing Facility 
(SNF) services you are requesting do not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
this does not meet criteria. Our physician reviewer found you do not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 x 4). 
 
You asked the Plan to pre-approve periodontal scaling. You say that you disagree with the denial for dental 
services. The Plan denied your request. The Plan says this service is covered by your dental benefits; however, 
your benefit for one periodontal scaling and root planing (D4341) per quadrants has 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. The Plan covers one 
periodontal scaling and root planing (D4341) per quadrant every two years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for periodontal 
scaling and root planing in the right quadrant provided on August 30, 2021, and the left quadrant on September 
3, 2021; therefore, the benefit for periodontal scaling and root planing has been exhausted. Therefore, we 
decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341 x 4).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 29, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 0037U is Targeted genomic sequence analysis, solid 
organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number 
amplifications, gene rearrangements, microsatellite instability and tumor mutational burden. 
 
We find that CPT code 0037U is not supported in the medical record. Specifically, the next generation 
sequence testing (NGS) testing panel performed included testing for the FANCC gene. Testing for this gene is 
not a Medicare benefit and is statutorily excluded service. In addition to single gene testing, panels that include 
the FANCC gene are statutorily excluded service. Based on this information, we decided that Medicare rules 
for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to 
pay for the FoundationOne CDx (F1CDx) test (0037U) provided January 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 7, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for lab services. You say that the enrollee did not come to the lab so he is not using 
out-of-network benefits. The Plan denied your request. The Plan says the services were not referred by a 
network provider and these services are not urgent or emergent, nor were they approved in advance. 
 
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 the lab services provided on February 7, 2022, by 
an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D1999, D2930, D0150, D0330) provided on 
December 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits and some of the services were performed out-of-network, non-network dentists 
have not agreed to provide services at contracted fees. If the member is to see an out-of-network dentist, the 
coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in their area. The 
member is responsible for the difference between the INFS and dentists' charged fees when visiting an out-of-
network dentist. 
 
  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 pay for dental 
services (D1999, D2930, D0150, D0330) provided on December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the lab tests were conducted in good faith. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the lab services at 
issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided 
that the Plan does not have to pay for the lab services provided on March 24, 2022, by an out-of-network 
(OON) provider.