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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from December 
29, 2021, to January 7, 2022. 
 You asked the Plan to pay for SNF care. You say that you would like this claim reprocessed and approved 
based on the medical records. The Plan denied your request. The Plan says the SNF care provided was not 
medically reasonable and necessary. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from December 29, 2021, to January 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that the testing is a covered service. The Plan denied 
your request. The Plan says the services were 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 file shows that the enrollee received an AlloSure Heart test. Although the lab service was billed with a 
valid CPT code, the provider in this case is not a network provider with the Plan. The Plan did not pre-approve 
the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for the lab services provided on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A5063 billed for date of service July 1, 2022. 
 
You asked the Plan to pay for code A5063. The Plan denied your request. The Plan says code A5063 is 
considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that code A5063 has a status indicator of P on the Physician Fee Schedule. This means that code 
A5063 is not separately payable. Based on this information, we decided that Medicare rules for coverage of code A5063 have not been met. Therefore, we decided that the Plan does not have to pay for code A5063 billed 
for date of service July 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening study for abdominal aortic aneurysm (AAA) 
(76706) provided on July 11, 2022. 
 
You asked the Plan to pay for an AAA screening. You say that this test was necessary and appropriate. The 
Plan denied your request. The Plan says the medical records provided are insufficient to show that the coverage 
criteria for this screening have been met. In addition, the diagnosis code billed on this claim is inappropriate. 
 
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 an AAA screening have been met. 
Specifically, the medical records provided do not indicate if the enrollee has a family history of abdominal 
aortic aneurysm, is a man aged 65 to 75 who has smoked at least 100 cigarettes in this lifetime, or manifests 
other risk factors in a beneficiary category recommended for screening regarding AAA. Without 
documentation showing that the enrollee meets one of these risk categories, we cannot confirm that the criteria 
for necessity of this screening have been met. Therefore, we decided that the Plan does not have to pay for 
screening study for abdominal aortic aneurysm (AAA) (76706) provided on July 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing rendered on May 17, 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 the services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, FANCC testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
FANCC genetic testing rendered on May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that a seat lift mechanism is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a seat lift 
mechanism. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 seat lift mechanism. Our reviewer 
says that the enrollee does not meet criteria for a seat lift mechanism. Our physician reviewer found the 
documentation does not reveal that the enrollee has severe arthritis of the hip or knee or has a severe 
neuromuscular disease. The seat lift mechanism is noted in the October 13, 2022, progress note. The 
documentation does not indicate that the enrollee is completely unable to stand up from a regular armchair or any chair in the home. The enrollee does have the ability to walk. The documentation does not support that the 
lift will have improvement in the enrollee's condition, or arrest or retard deterioration in the enrollee's 
condition. The seat lift mechanism criteria have not been 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 a seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested item is 
experimental/investigational. 
 
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 MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro 
orthosis is not in widespread use based on scientific evidence. There is insufficient evidence in the literature 
that the MyoPro orthosis will improve long-term outcomes for the enrollee, improve hemiparetic arm function, 
or be safe for long-term use. There is insufficient evidence in the literature that the device will 
increase participation in bimanual activities. 
 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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 17, 2021, to 
June 27, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
documentation supports the principal diagnosis code as originally billed. The Plan denied your request. The 
Plan says the medical documentation does not support the billed principal diagnosis code. 
 
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 principal diagnosis code, J96.10, defined as 
secondary malignant neoplasm of brain. 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 documentation does not 
support the inpatient hospital services as billed with a principal diagnosis code of C79.31, defined as secondary 
malignant neoplasm of brain. Our physician reviewer found that the enrollee was a then, 74-year-old female 
with a history of chronic obstructive pulmonary disease, hypertension, hyperlipidemia, and adenocarcinoma of 
the lung with adrenal and brain metastases. The enrollee was admitted on June 17, 2022, with difficulty 
swallowing and shortness of breath. On evaluation her O2 saturation was 89% at rest and decreased to 70% 
with ambulation. She had chest x-ray evidence of infiltrates. While hospitalized she underwent stereotactic 
brain radiosurgery of a brain lesion on June 23, 2021. She was to undergo radiation therapy to the brain. 
Per Medscape Internal Medicine, a malignant brain tumor is a fast-growing cancer that spreads to other areas of 
the brain and spine. Generally, brain tumors are graded from 1 to 4, according to their behavior, such as how 
fast they grow and how likely they are to grow back after treatment. The review indicates that the enrollee was 
admitted for treatment of her pulmonary condition. The review has determined that the documentation did not 
support the billed principal diagnosis code C79.31, defined as secondary malignant neoplasm of brain.  
 
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 on June 17, 2021, to June 27, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 42 hours per week (6 hours per day) of home health aide 
(HHA) services (G0156). 
 
You asked the Plan to pre-approve the hours. You say that this is medically necessary. The Plan denied your 
request. The Plan says 28.5 hours per week of HHA services is enough to meet your needs. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 hours. Our reviewer says that the 
requested additional hours are not medically reasonable or necessary. Our physician reviewer found that your 
care needs are custodial. As such, the additional hours beyond what was approved 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 the hours have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 42 hours per week (6 hours per day) of home health aide (HHA) services (G0156).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR) with a 
prosthetic valve. 
 
You asked the Plan to pre-approve TAVR with a prosthetic valve. 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 follows Medicare rules. Medicare rules say that TAVR is covered for the treatment of symptomatic 
aortic valve stenosis when furnished according to a Food and Drug Administration (FDA)-approved indication 
and when specific criteria are met. 
 
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 TAVR with a prosthetic valve. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found documentation 
indicates that the severity of the stenotic gradient is not severe, with calculated valve area of over 1.0 cm2. 
Guidelines would not support aortic valve replacement based on the submitted medical records. As a result, at 
this time the requested TAVR would not be considered medically necessary in your clinical management based 
on the submitted documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TAVR with a prosthetic valve have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR) with a prosthetic valve.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays 2 or more genes in a patient 
in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single 
procedural service, so 1 code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services provided on June 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that a bilevel was tried and failed by the 
enrollee already and it did not effectively resolve the enrollee's condition. The Plan denied your request. The 
Plan says the ventilator is not necessary. 
 
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 the home ventilator. Our physician 
reviewer found arterial blood gas (ABG) on November 15, 2022, shows a normal PaCO2 of 42. Therefore, 
ventilatory support during sleep is not indicated.  If the enrollee did have chronic carbon dioxide (CO2) 
retention, bilevel positive airway pressure (BiPAP) could be used with average volume-assured pressure 
support (AVAPS). The denial is upheld. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81265, 81266) provided on March 2, 
2022. 
 
You asked the Plan to pay for laboratory services. You say that this testing was necessary. The Plan denied 
your request. The Plan says the CLIA number submitted on this claim is invalid. Therefore, this claim cannot 
be processed until this number is corrected. 
 
The Plan must follow Medicare rules. Medicare rules say that any independent laboratory performing tests 
covered by CLIA must submit the CLIA number on the claim. Laboratory claims submitted without the 
required CLIA number are returned as unprocessable. If the CLIA number is submitted on the claim, but is 
inconsistent with the CLIA format, the A/B MAC (B) returns the claim as unprocessable. We looked at the file and Medicare rules. The CLIA number submitted on this claim is invalid. Based on this 
information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, 
we decided that the Plan does not have to pay for laboratory services (81265, 81266) provided on March 2, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 15, 2022, billed with 
multiple codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is medically necessary genetic 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 
June 15, 2022, billed with multiple codes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee. 
 
You asked the Plan to pre-approve the requested services. You say that a microprocessor knee will improve the 
enrollee's function. The Plan denied your request. The Plan says the enrollee has not tried and failed a level 3 
mechanical knee. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of left-sided above the knee amputation. In this case, the 
documentation supports the medical necessity for a replacement level 3 prosthesis. However, there is no 
indication that the enrollee requires a microprocessor knee instead of a mechanical knee.   
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee.
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 services requested are medically 
necessary. The Plan denied your request. The Plan says the services requested are not medically necessary. 
 
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 medical record does not indicate that the enrollee requires services that she is not 
currently receiving. The enrollee still requires acute care services before transitioning to a lower 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the member's needs can be met at a lower level of care and does not 
have needs that would require a SNF level of care. 
 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided there is no documentation that the patient 
requires skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.