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

 
We decided that the Plan does not have to pay for the prostate specific antigen (PSA) testing received on 
January 21, 2021. 
 
You asked the Plan to pay for the PSA testing. You say that your doctor has been keeping an eye on your PSA 
levels. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that prostate specific antigen testing is only covered 
once per year. 
 
We looked at the file and Medicare rules. Review of the file shows that you received PSA testing on January 
21, 2021. You previously received PSA testing on April 13, 2021, which was processed by the Plan. A year 
had not passed since you previously received this test. No medical documentation was provided to support that 
you have had a change in medical condition. Based on this information, we decided that Medicare rules for 
coverage of the PSA testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the prostate specific antigen (PSA) testing received on January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx panel for prostate cancer provided on May 
12, 2021. 
 
You asked the Plan to pay for the SelectMDx panel for prostate cancer. You say that this testing is useful to 
help predict the likelihood of cancer being found on biopsy. The Plan denied your request. The Plan says this 
was done for screening purposes. 
 
Medicare rules say that MDT panels such as SelectMDx are subject to the MolDX application, assessment, and 
approval process. Once this is complete, the test is assigned a reimbursement rate and unique test identifier.  
We looked at the file and Medicare rules. The DEX Diagnostics Exchange Registry shows that this test was 
reviewed through the MolDX process and was determined to be not covered by Medicare. Based on this 
information, we decided that Medicare rules for coverage of the SelectMDx panel for prostate cancer have not 
been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx panel for prostate cancer 
provided on May 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services billed with diagnosis related group 
(DRG) 947 provided from May 12, 2021 to May 15, 2021. 
 
You asked the Plan to pay for the inpatient services billed with DRG 947. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by 
the documentation. 
 
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 secondary diagnoses codes of J96.01 Acute 
Respiratory Failure with Hypoxia, J18.9 Pneumonia Unspecified Organism, and I62.00 Nontraumatic Subdural 
Hemorrhage, Unspecified. 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 
services billed with DRG 947. Our reviewer says that the documentation does not support the DRG billed. Our 
physician reviewer found the documentation supported an admission for Delirium. The documentation was 
inconsistent/unclear regarding the diagnoses of Acute Respiratory Failure, Pneumonia, and Nontraumatic 
Subdural Hemorrhage. The enrollee presents with increased agitation and combativeness. The enrollee had 
recent prior hospitalization for Covid with hypoxia and pneumonia. Emergency room physical exam states non 
labored respirations, lungs are clear. Pulmonology states not hypoxemic at this time, x-ray shows chronic 
changes from recent Coronavirus infection. Per Infectious disease, even though Coronavirus screen is still 
positive it is unlikely the enrollee has active infection, no indication for antibiotics. Per Neurology, initial 
computed tomography (CT) brain read by radiology as possible interhemispheric subdural probably 
calcification which was tiny. Neurology states really feel likely inconsequential. Atypical Pneumonia is listed 
in the Assessment List. Acute Respiratory Failure is only documented by the Pulmonologist. Pneumonia nor 
Acute Respiratory Failure are discussed in Hospitalist?s Progress Notes. Discharge Summary states CT brain 
showed questionable tiny subdural hemorrhage. Discharge Diagnoses in discharge Summary do not include 
Pneumonia, Acute Hypoxemic Respiratory Failure or Nontraumatic Subdural Hemorrhage. Therefore, the 
services are not payable as billed.  
 
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 the inpatient services billed with diagnosis related group (DRG) 947 provided from May 12, 2021 to May 
15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the take home supply of methadone and medication assisted 
treatment provided by an out-of-network from May 15, 2021, through July 17, 2021. 
 
You asked the Plan to pay for the take home supply of methadone and medication assisted treatment. You say 
that you were paying $30 a week but had to switch clinics and you cannot afford this cost. The Plan denied 
your request. The Plan says the services were not authorized and four of the claims denied due to incorrect 
coding. 
 
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 take home supply of methadone and 
medication assisted treatment provided by an out-of-network from May 15, 2021, through July 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are very weak and have not walked without 
assistance. The Plan denied your request. The Plan says the stay is not medically necessary. 
 
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 an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical management of gastric adenocarcinoma. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented 
need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve an incisional biopsy of oral tissue. You say that the service at issue is 
medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 pre-approve an 
incisional biopsy of oral tissue (D7286).
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve Optimizer Smart permanent cardiac contractility modulation 
system (CPT code 0408T), for the enrollee. 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that a review of the current medical literature indicates that the Optimizer 
system is considered experimental and investigational, as it is not identified as widely used and generally 
accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published 
in the English language. 
 
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 service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found cardiac contractility modulation therapy with the Optimizer device is a relatively newer 
technology which is Food and Drug Administration (FDA) approved, and has some randomized data showing 
modest benefit with regard to quality of life and walk time scores in patients already on maximal medical 
therapy. A recent randomized clinical trial (160 patients) who were also already on optimal guideline directed 
medical therapy for congestive heart failure (CHF), showed improvement in peak VO2, improved exercise 
tolerance on six (6) minute walk, quality of life scores and re-hospitalization episodes. This enrollee has 
persistent Class III symptoms, an elevated brain natriuretic peptide (BNP) and is on full guideline directed 
medical therapy for CHF. The enrollee has a moderately reduced EF in the 25-45% range and the enrollee's 
QRS is not prolonged, and the enrollee would not be a candidate for cardiac resynchronization therapy (CRT) 
therapy either. Based on the published data, expert opinion and the approved FDA indications, the enrollee 
would therefore meet Centers for Medicare & Medicaid Services (CMS) criteria for medical reasonableness 
and necessity of this device based on the applicable CMS Section 1862(a)1(A) 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 service have been met. Therefore, we decided that the Plan has to pre-
approve Optimizer Smart permanent cardiac contractility modulation system (CPT code 0408T), for the 
enrollee.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on June 3, 2021. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you cannot afford the 
services as you are on a fixed income. The Plan denied your request. The Plan says the cost sharing applied 
correctly based on the services provided. 
 
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 $445 
copayment for Ambulance services.  
 
 
 You have been asked to pay a $445 copayment for ambulance transportation. 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 ambulance transportation services provided on June 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of this drug in this case requires unresectable or metastatic disease that is 
microsatellite instability-high (MSI-H) and/or deficient mismatch repair (dMMR). 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found Pembrolizumab would 
be indicated if the patient was found to be MSI-H or dMMR. However, no results for these are provided. The 
service is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs SNF services to return to her 
previous condition. The Plan denied your request. The Plan says that the enrollee's needs can be appropriately 
and safely met in a long term care facility with part time skilled services. 
 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 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for drug testing (G0483) provided on May 11, 2021. 
 
You asked the Plan to pay for drug testing. You say that this was billed correctly. The Plan denied your request. 
The Plan says that the documentation does not support that 22 or more drug classes were tested. 
 
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 G0483 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; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the submitted records show that 
more than 22 drug classes were tested. The tested classes include Alcohol biomarkers; Amphetamines; 
Antidepressants, serotonergic class; Antidepressants, tricyclic and other cyclicals; Antidepressants, not 
otherwise specified; Antipsychotics, not otherwise specified; Barbituates; Benzodizepines; Buprenorphine; 
Cannabinoids, natural; Cannabinoids, synthetic; Cocaine; Fentanyls; Gabapentin, non-blood; Heroin 
metabolite; Ketamine and Norketamine; Methadone; Methylenedioxyamphetamines; Opiates; Opioids and 
opiate analogs; Oxycodone; Phencyclidine; Pregabalin; Propoxyphene; Sedative Hypnotics (non-
benzodiazepines); Skeletal muscle relaxants; Stimulants, synthetic; Tapentadol; and Tramadol  Based on this 
information, we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided 
that the Plan has to pay for drug testing (G0483) provided on May 11, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Diphenhydramine, Rituximab, Hydrocortisone for the enrollee. 
 
You asked the Plan to pre-approve the drugs. You say that this is a treatment plan that is needed for lymphoma. 
The Plan denied your request. The Plan says that there are not enough studies to prove that this combination of 
drugs works well. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the drugs. Our reviewer says that the 
requested drugs are medically reasonable and necessary. Our physician reviewer found several trials have 
demonstrated efficacy with the use of maintenance rituximab in overall and disease-free survival for 
relapsed/refractory mantle cell lymphoma. the use of maintenance rituximab is reasonable and medically 
necessary and likely to be safe and effective for this enrollee. 
 
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 drugs have been met. Therefore, we decided that the Plan has to pre-approve 
Diphenhydramine, Rituximab, Hydrocortisone for the enrollee.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (29823) provided on April 28, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is 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 29823 is "Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])".  

 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 code 29823 is not supported by the records provided. 

Our reviewer found that the operative report does not support extensive debriding to include 3 or more discrete structures (humeral bone, humeral articular cartilage, glenoid bone, glenoid artiular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body(ies)). The operative report describes debridement of labrum, and synovitis was removed.  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 (29823) provided on April 28, 2021.