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

 
We decided that the Plan does not have to pre-approve breast reduction surgery/reduction mammaplasty. 
 
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 services were deemed to be cosmetic and 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 the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the enrollee in this case has had significant symptoms that 
have interfered with normal daily activities, despite conservative management, for at least six months. 
 
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 breast reduction surgery/reduction mammaplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar/bath handle shower. 
 
You asked the Plan to pre-approve a grab bar. You say that you need this item. The Plan denied your request. 
The Plan says this item is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a grab bar/bath handle shower.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for gene analysis provided to the enrollee on December 6, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned for insufficient information regarding the denial. The Plan requested a reopen and provided additional information. The Plan noted that the provider has billed six different procedure codes for the comprehensive cardiovascular NGS panel. This is incorrect as the provider 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. The Medicare billing guidelines, NCCI Chapter X Pathology / Laboratory Services (codes 80000 - 89999) section "F. Molecular Pathology" stated if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory must report only one unit of service. If no code accurately describes the procedure performed, the laboratory may report code 81479 (Unlisted molecular pathology procedure) with one unit of service. Procedures reported together must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician who is treating the enrollee where the results will directly affect management of the specific medical problem.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes.
In this case, this claim was not billed with the appropriate code for the service provided. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for gene analysis provided to the enrollee on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93320 billed for date of service October 12, 
2022. 
 
You asked the Plan to pay for procedure code 93320. You say that this service is supported as billed. The Plan 
denied your request. The Plan says this service is not supported in the medical record. 
 
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 93320 is doppler echocardiography, pulsed wave and/or 
continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); 
complete. 
 
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 procedure code 93320. Our reviewer says that code 93320 is 
not supported in the medical record. Our reviewer found the documentation shows that a transesophageal echocardiography was performed, billed and paid for CPT code 93312. However, the provided records in this 
case do not clearly document that doppler echocardiography, pulsed wave and/or continuous wave with 
spectral display was also performed on the date in question. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 93320 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 93320 billed for date of service October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 8, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical and occupational therapy services to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you cannot go to an outside provider. The Plan 
denied your request. The Plan says there are available participating providers. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
physical and occupational therapy services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance for a continuous glucose monitor (CGM) 
provided on September 5, 2022. 
 
You asked the Plan to pay for supply allowance for CGM. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the items billed are not supported. 
 
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 or relevant medical records which support medical 
necessity for the supplies provided in this case. Review of the file shows that the submitted medical records do 
not include a matching billed date and date the enrollee received the supplies. The medical records show a 
different billed date of service than the shipping invoice and the delivery ticket. 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 supply allowance for a continuous glucose monitor (CGM) provided on 
September 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on July 11, 
2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
July 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SurgiMend Collagen Matrix. 
 
You asked the Plan to pre-approve SurgiMend Collagen Matrix. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SurgiMend Collagen Matrix. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found review of currently available literature does not sufficiently support 
SurgiMend is safer and more effective than standard of care treatment options for this clinical situation. 
Therefore, the SurgiMend Collagen Matrix will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SurgiMend Collagen Matrix have not been met. Therefore, we decided that the 
Plan does not have to pre-approve SurgiMend Collagen Matrix.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF assay provided on September 5, 2022. 
 
You asked the Plan to pay for the Tempus xF assay. You say that the Tempus xF assay is medically necessary. 
The Plan denied your request. The Plan says the Tempus xF assay does not meet the Medicare NCD coverage 
criteria. 
 
The Plan follows Medicare rules. 
 
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 Tempus xF assay. Our reviewer says that 
the Tempus xF assay is not medically necessary. Our physician reviewer found that the documentation 
indicates that the diagnosis listed is cutaneous B-cell lymphoma and neoplasm of uncertain behavior. No 
clinical notes were submitted despite multiple attempts to obtain records. There is no clinical indication 
whether the cancer is recurrent, relapsed, refractory, or advanced. The review has determined that the requested 
genetic panel test described as Tempus xF does not meet the Medicare NCD 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 Tempus xF assay have not been met. Therefore, we decided that the Plan 
does not have to pay for genomic sequencing procedures and Other molecular multianalyte assays (code 
81455)-the Tempus xF assay provided on September 5, 2022.
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 requesting an expedited 
reconsideration for the denial of an LTACH admission based on medical complexity and history. The Plan 
denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in 
transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs. 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint denervation. 
 
You asked the Plan to pre-approve facet joint denervation. 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 the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who meet specific criteria. 
 
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 facet joint denervation. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee did not have two 
(2) medically reasonable and necessary diagnostic medial branch blocks (MBBs), with each one providing a 
consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being 
consistent with the agent used). The review has determined that the enrollee does not meet the coverage criteria 
in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint denervation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint denervation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
to another provider, by the Plan on October 13, 2022. Comparison of the two claims shows these are exact 
duplicates, except for the provider. There is no evidence presented to support that the billed items/services were 
provided twice on the same date. Based on this information, we decided that the Medicare rules for the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on October 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (25118, 25652) provided on October 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 25118 is "Synovectomy, extensor tendon sheath, wrist, 
single compartment". The CPT Code Manual definition of code 25652 is "Synovectomy, extensor tendon 
sheath, wrist, single compartment". 
 
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 use of codes 25118 
and 25652 is not supported by the records provided. Our reviewer found that there is no evidence that a 
synovectomy of a tendon sheath was performed. The record states that the tendon sheath was incised as part of 
the neuroplasty (reported separately with an approved CPT code), but the sheath was not removed. 
Additionally, there is no documentation of a fracture of the ular styloid. The distal ulna was fractured and the ulnar styloid was used to hold fixation in place. There is a more specific code for treatment of a distal ulnar 
fracture. 
 
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 the services (25118, 25652) provided on October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor ankle/foot. 
 You asked the Plan to pre-approve microprocessor ankle/foot. You say that there is no alternative foot that can 
provide stability and function. The Plan denied your request. The Plan says the enrollee is not a level 3 
ambulator and the enrollee's needs can be met with a level 2 mechanical knee. 
 
The Plan follows Medicare rules. Medicare rules state that a microprocessor ankle/foot is covered for enrollees 
whose functional level is 3 or above. 
 
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 microprocessor ankle/foot. Our 
reviewer says that the enrollee does not meet criteria for this foot. Our physician reviewer found the records do 
not support that the enrollee is a level 3 ambulator to meet criteria for the requested microprocessor ankle/foot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of microprocessor ankle/foot have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a microprocessor ankle/foot.
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 are medically necessary for 
the enrollee to receive the care needed. The Plan denied your request. The Plan says the enrollee can remain in 
the current acute care location until such time no further acute level care is needed. 
 
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 documentation does not support that the enrollee has a need for complex medical 
treatment in a LTACH. The enrollee 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. 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve injections. You say that these are medically necessary for the enrollee. The 
Plan denied your request. The Plan says that injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint procedure performed after anterior lumbar 
interbody fusion (ALIF) is considered not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve injections. Our reviewer says that the 
injections are not medically necessary. Our physician reviewer found the provided documentation indicates the 
enrollee has had a fusion at L3 to L5. Therefore, the reviewer found that the requested injections 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve facet joint injections (64493, 64494).