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

 
We decided that the Plan does not have to pre-approve bilateral L3-4, L4-5 and L5-S1 hemilaminotomies. 
 
You asked the Plan to pre-approve bilateral L3-4, L4-5 and L5-S1 hemilaminotomies. You say that the 
requested bilateral L3-4, L4-5 and L5-S1 hemilaminotomies are medically necessary. The Plan denied your 
request. The Plan says the requested bilateral L3-4, L4-5 and L5-S1 hemilaminotomies are 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 bilateral L3-4, L4-5 and L5-S1 
hemilaminotomies. Our reviewer says that the requested bilateral L3-4, L4-5 and L5-S1 hemilaminotomies are 
not medically necessary. Our physician reviewer found there is no documentation of adequate conservative 
measures for lower back pain to include 6 weeks of formal physical therapy. There are no red flags for surgery. 
The requested bilateral L3-4, L4-5 and L5-S1 hemilaminotomies are 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 bilateral L3-4, L4-5 and L5-S1 hemilaminotomies have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral L3-4, L4-5 and L5-S1 
hemilaminotomies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiomyopathy testing (81439) provided on 
December 2, 2020. 
 
You asked the Plan to pay for the hereditary cardiomyopathy testing. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this testing is not 
a covered benefit. 
 
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 pay for the hereditary cardiomyopathy testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the test is described as a genetic based cardiovascular risk factor screening 
test in which multiple genes are assessed using genomic DNA extracted from patient sampling. It assesses the 
presence of pathogenic or likely pathogenic variants in genes known to be associated with increased cardiac 
risk. It is not a diagnostic test. There is no evidence to support its role in this enrollee's clinical management. 
 
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 hereditary cardiomyopathy testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the hereditary cardiomyopathy testing (81439) provided on 
December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle-foot orthotics provided on December 27, 2021. 
 
You asked the Plan to pay for ankle-foot orthotics. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for these items is correct, because the records do 
not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that proof of delivery is required to determine 
payment for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items.  
 
We looked at the file and Medicare rules. The records submitted do not include valid proof of delivery for the 
billed items. Specifically, the delivery ticket and proof of delivery submitted do not specify delivery of the 
specific items billed on this claim. Based on this information, we decided that Medicare rules for coverage of 
ankle-foot orthotics have not been met. Therefore, we decided that the Plan does not have to pay for ankle-foot 
orthotics provided on December 27, 2021.
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 have improved somewhat but has worsened again is still 
unstable and should only require short-term acute care services to safely complete care until more stable for 
discharge to 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 may be considered when treatment has 
completed. 
 
 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: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to adjust the copayment for the x-ray examination of the colon (74270) provided 
on November 30, 2021. We also decided that the Plan does not have to waive the copayment for this service.  
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plans 
denial for payment. The Plan says the copayment has been applied correctly to the service provided.  
 
 
 We decided that the Plan has to adjust the copayment for the x-ray examination of the colon (74270) 
provided on November 30, 2021. The cost sharing applied in this case by the Plan referenced a $98.05 
copayment for a Medicare-covered radiological diagnostic service provided. However, the Plan contract states 
that a $15 copayment applies to each Medicare-covered standard x-ray service. The service provided in this 
case was incorrectly processed as a Medicare-covered radiological diagnostic service. Therefore, we decided 
that the Plan has to adjust the copayment from $98.05 to $15 for the x-ray examination of the colon (74270) 
provided on November 30, 2021.  
 
We also decided that the Plan does not have to waive the copayment for the x-ray examination of the 
colon (74270) provided on November 30, 2021. 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 $15 copayment for each Medicare-covered standard x-ray 
service. Therefore, we decided that the Plan does not have to waive the copayment for the x-ray examination of 
the colon (74270) provided on November 30, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from December 3, 2021, 
through December 10, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these services have been billed incorrectly 
based on Medicare rules. 
 
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 the medical services provided from December 3, 2021, through December 10, 2021 have been met. In this case, no medical records were provided 
to corroborate the services as they have been billed. Therefore, we decided that the Plan does not have to pay 
for the medical services provided from December 3, 2021, through December 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee has swelling into her 
abdomen and skin changes. The Plan denied your request. The Plan says there is no documentation of edema of 
the abdomen or thorax. 
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications.  
 
The file shows that an advanced pneumatic compression device, coded E0652, was requested. 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 device. Our physician reviewer found that 
the enrollee has a history of venous insufficiency and is status post multiple endovenous ablative procedures.  
On physical examination it was documented that she had no edema. In January 2022, her edema is described as 
1+ pretibial and ankle edema. The documentation does not demonstrate that she has undergone any formal 
lymphedema treatments. The current request is for an advanced lymphedema pump, however, there is no 
documentation that she has failed simpler, even segmented pumps. There are no unique features of this 
enrollees condition that would necessitate an advanced pump. 
 
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 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a pneumatic compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement (11044) provided on September 14, 2021. 
 
You asked the Plan to pay for debridement (11044). You say that the procedure involved required debridement 
to the bone and you anticipate prompt payment. The Plan denied your request. The Plan says the 
documentation does not support CPT code 11044. 
 
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 11044 is debridement, bone (includes epidermis, dermis, 
subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less. 
 
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 debridement (11044). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the procedure report does not meet CMS guidelines for reporting debridement. The documentation submitted 
does not contain the total surface area of the wound debrided.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of debridement (11044) have not been met. Therefore, we decided that the Plan 
does not have to pay for debridement (11044) provided on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing (81407, 81408x2, 81479x2 
and 81286) provided on May 14, 2021. 
 
You asked the Plan to pay for the cardiovascular genetic testing. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this testing is not a covered 
benefit. 
 
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 pay for the cardiovascular genetic testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the test is described as a genetic based cardiovascular risk factor screening 
test in which multiple genes are assessed using genomic DNA extracted from patient sampling. It assesses the 
presence of pathogenic or likely pathogenic variants in genes known to be associated with increased cardiac 
risk. It is not a diagnostic test. There is no evidence to support its role in this enrollee's clinical management. 
 
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 cardiovascular genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the cardiovascular genetic testing (81407, 81408x2, 81479x2 and 81286) 
provided on May 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that 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 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 the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the bi-level positive airway pressure (BiPAP) device provided on 
December 9, 2021. 
 
You asked the Plan to pay for the BiPAP device. You say that this claim should be reprocessed by the Plan. 
The Plan denied your request. The Plan says that the claim has processed correctly in this case. 
 
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, very little information was provided regarding why this claim is 
denying. Specifically, the denial language indicates that payment is limited to the agreed upon rental amount or 
purchase price and that no additional payment will be made for this equipment. There is no documentation 
provided that any payment has already been made for this service. Without a clear denial reason, we are unable 
to verify the Plans argument denying coverage. Therefore, we decided that the Plan has to pay for the bi-level 
positive airway pressure (BiPAP) device provided on December 9, 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 pay for the durable medical equipment provided on February 8, 
2021, to March 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the durable medical equipment provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-
network care. 
 
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 durable medical equipment provided on 
February 8, 2021, to March 8, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on July 1, 2021. 
 
You asked the Plan to pay for genetic testing. You say that the proper usage of Place of Service (POS) code 81 
has been included on this claim. The Plan denied your request. The Plan says the denial of payment for this 
testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed 
on this 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 genetic testing 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 genetic testing provided on July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate lymphatic reconstruction provided on August 
9, 2021. 
 
You asked the Plan to pay for the immediate lymphatic reconstruction. You say that this care was medically 
necessary and should be reprocessed by the Plan. The Plan denied your request. The Plan says this claim will 
not be paid as there is insufficient evidence to support the use of immediate lymphatic reconstruction during 
breast cancer surgery for the prevention of lymphedema. 
 
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 pay for the immediate lymphatic reconstruction. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has breast cancer. UptoDate indicates 
that the largest series evaluating the requested service is comprised of 74 patients and has not been validated. 
There is insufficient literature to establish the requested procedure as safe and efficacious, as defined by 
Medicare rules, for the enrollee's clinical condition. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are not satisfied. 
 
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 immediate lymphatic reconstruction have not been met. Therefore, we 
decided that the Plan does not have to pay for the immediate lymphatic reconstruction provided on August 9, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (EKG) (93010) provided on September 
26, 2021. 
 
You asked the Plan to pay for EKG 93010. You say that you do not agree with the decision to deny payment. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 93010 has a procedure-to-procedure (PTP) edit of 1 with code 64447 so is not separately payable without an 
appropriate modifier. 
 
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, we have confirmed that code 93010 
is a column II code to column I code 64447. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for an electrocardiogram (EKG) (93010) provided on September 26, 
2021.