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

 
We decided that the Plan has to pay for the complete bilateral noninvasive physiologic studies of upper or 
lower extremity arteries (93923) provided on October 13, 2021. 
 
You asked the Plan to pay for the extremity study. You say that missing information has been provided. You 
also say that the service was medically necessary. The Plan denied your request. The Plan says that it cannot be 
determined if the service in this case was medically necessary. 
 
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 pay for the extremity study. Our reviewer says that 
the extremity study is considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation indicates struggle with extremity pain with ambulation, decreased pulses, 
and notes that their distal bilateral lower extremities are cold. Therefore, the reviewer found that the study 
performed was reasonable and 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 extremity study have been met. Therefore, we decided that the Plan has to 
pay for the complete bilateral noninvasive physiologic studies of upper or lower extremity arteries (93923) 
provided on October 13, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 the enrollee appears to be stable and should only require short-term additional acute 
care services that can be administered safely at the current facility until appropriate for a lower level of care as 
it appears they are not a good candidate for weaning. There are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility. Transfer to LTACH is not medically 
necessary at this time as it would not be clinically advantageous. Completion of treatment at the current facility 
is 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from February 7, 2020, to 
February 12, 2020, as billed with Diagnosis Related Group (DRG) 193. 
 
You asked the Plan to pay for inpatient care as billed with DRG 193. You say that these services were 
medically necessary and are supported in the record. The Plan denied your request. The Plan says DRG 193 is not appropriate as the diagnosis of acute respiratory failure with hypoxia (J96.01) is not supported in the 
medical record. The Plan argues that DRG 194 is more appropriate in this case. 
 
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. 
 
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 inpatient care as billed with DRG 193. Our 
reviewer says that the diagnosis of acute respiratory failure with hypoxia (J96.01) is not supported in the 
medical record for this inpatient admission. Our physician reviewer found that the enrollee with a history which 
included asthma, chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea on nocturnal 
continuous positive airway pressure (CPAP) machine presented for evaluation in February of 2020, reporting 
difficulty breathing and productive cough. Viral testing revealed the presence of Influenza A antigen. A chest 
x-ray revealed low lung volumes with bronchovascular crowding and left lung base subsegmental atelectasis 
versus consolidation. A repeat chest x-ray on February 11, 2020, revealed improvement in lung volumes, likely 
small bilateral pleural effusions with passive atelectasis, and mild retrocardiac atelectasis concerning for 
consolidation. The enrollee was admitted for the ongoing evaluation and management of pneumonia, Influenza 
A and COPD exacerbation. Treatment included intravenous antibiotics, TamiFlu, intravenous steroids, 
bronchodilator medication and supplemental oxygen at 2L per minute. Prior to discharge, a "walking 
desaturation study" reportedly revealed pulse oximetry reading of 88% or greater. The enrollee was discharged 
back to the originating skilled nursing facility without supplemental oxygen. There was no evidence of acute 
respiratory failure with hypoxia during the hospitalization. The review has determined that the medical records 
did not support the billing of acute respiratory failure with hypoxia (J96.01). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care as billed with DRG 193 have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided from February 7, 2020, to 
February 12, 2020, as billed with Diagnosis Related Group (DRG) 193.
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 the enrollee appears to be stable and improving and should only require short-term 
additional acute care services that can be administered safely at the current facility until appropriate for a lower 
level of care. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to LTACH is not medically necessary at this time as it would not be 
clinically advantageous. Completion of treatment at the current facility is 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 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx testing provided on December 15, 2021. 
 
You asked the Plan to pay for the FoundationOne CDx testing. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication.  
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. Based on this information, we decided 
that Medicare rules for coverage of the FoundationOne CDx testing have been met. Therefore, we decided that 
the Plan has to pay for the FoundationOne CDx testing provided on December 15, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colorectal cancer screening (G0121). 
 
You asked the Plan to pre-approve the screening test. You say that your last screening was done is 2017. You 
also say that you are due for another one as 5 years has passed. The Plan denied your request. The Plan says the 
requested service is 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 screening test. Our reviewer says 
that the requested cancer screening is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not indicate that the enrollee is at high risk based 
on the results of their previous screening in 2017. Therefore, the reviewer found that the repeat cancer 
screening is not medically reasonable or 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 the screening test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a colorectal cancer screening (G0121).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the initial nursing facility care (99305) provided on October 19, 2020. 
 
You asked the Plan to pay for the nursing facility care. You say that the medically necessary services were 
rendered to the enrollee in good faith. The Plan denied your request. The Plan says that the claim was not 
received within 12 months of the date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided documentation to support their denial. 
The file indicates that the initial claim for the service at issue in this case was received within 12 months from 
the date of service. Therefore, we decided that the Plan has to pay for the initial nursing facility care (99305) 
provided on October 19, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 15, 2021 billed 
with codes 81220, 81226, 81306, 81328, 81227, 81231, 81232, 81232 and 81283. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not billed correctly. 
 
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 
September 15, 2021 billed with codes 81220, 81226, 81306, 81328, 81227, 81231, 81232, 81232 and 81283.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound care to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve wound care to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 
wound care 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 a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that there are no network providers 
with similar credentials and expertise for services provider in the enrollee's area at the time the provider was 
assigned. The Plan denied your request. The Plan says pneumatic compression device is not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
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 January 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. 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 January 
12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on April 
11, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you received a routine device 
check and should not be charged an office visit copayment. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each specialist visit.  
 
 
 
 
 
 
 You have been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical 
assessment (90792) provided March 7, 2022. 
 
You asked the Plan to pay for the psychiatric services. You say that you were referred to this provider by 
someone close to you. You have out of network benefits and thought the services would be covered by the Plan 
and request reimbursement. The Plan denied your request. The Plan says if you go to a provider who is not 
eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
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 appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
psychiatric diagnostic evaluation with medical assessment (90792) provided March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the knee immobilizer received on August 
31, 2021. 
 
You asked the Plan to waive the coinsurance for the knee immobilizer. You say that you did not receive this 
item. The Plan denied your request. The Plan says the claim has been processed correctly per your Plan 
benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Durable Medical Equipment.  
 
You have been asked to pay 20% coinsurance for the knee immobilizer. The knee immobilizer falls within the 
Durable Medical Equipment benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the knee 
immobilizer received on August 31, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97530, 97110) provided from 
February 25, 2022, to March 2, 2022. 
 
You asked the Plan to pay for physical therapy. You say that the diagnosis code used on this claim is valid and 
correct. The Plan denied your request. The Plan says the diagnosis code reported on this claim was not reported 
in accordance with Medicare billing guidelines. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that diagnosis codes for unspecified side should rarely be used, such as when the documentation in 
the record is insufficient to determine the affected side and it is not possible to obtain clarification. 
 
We find that the ICD-10 code reported on these claims, M25.519 (pain in unspecified shoulder), is not the most 
accurate and specific diagnosis available based on the records provided. Specifically, the physician referral for 
physical therapy services indicates that the enrollees pain is in the left shoulder. Because this information is 
available, the code for an unspecified side should not be used. Based on this information, we decided that 
Medicare billing rules have not been met. Therefore, we decided that the Plan does not have to pay for physical 
therapy services (97530, 97110) provided from February 25, 2022, to March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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 lab services provided on July 5, 2021.