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

 
We decided that the Plan does not have to pay for molecular pathology services (Tempus gene panel) provided 
to the enrollee on May 19, 2021.  
You asked the Plan to pay for the services. You say that this is a valuable tool when determining treatment. The 
Plan denied your request. The Plan says more prospective trials are needed to better define in choosing 
clinically actionable genomic testing in urothelial cancer in the adjuvant settings. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found molecular pathology services (Tempus gene panel) were provided to the enrollee on May 19, 2021. 
Based on the provided records, his kidney dysfunction disqualifies him for cisplatin. He had been evaluated for 
a clinical trial. The genetic testing would not provide useful information for this enrollee. The SIVA trial 
showed that molecular testing was no advantage to treatment at the physician's choice for a patient with 
pretreated cancer such as in this case. Therefore, without sufficient supportive evidence for this testing, the 
molecular pathology services (Tempus gene panel) will be considered not 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for molecular pathology services (Tempus gene panel) provided to the enrollee on May 19, 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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee continues to receive acute care services and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility. 
 
 
 
  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this device is medically reasonable 
and necessary. The Plan denied your request. The Plan says there are not enough studies to show Vertiflex 
Superion is safe and effective to treat back pain 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and 
efficacy. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound coded 76856 provided on March 30, 2021. 
 
You asked the Plan to pay for the ultrasound. 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 services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 76856 is ultrasound, pelvic (nonobstetric), real time with 
image documentation; complete. 
 
We find that CPT code 76856 is not supported in the medical record. Specifically, the submitted medical 
records support that a complete ultrasound, pelvic (nonobstetric), real time with image documentation was 
performed. This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we 
decided that the Plan does not have to pay for the ultrasound coded 76856 provided on March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a prefabricated hip orthosis (L1686) and addition to lower 
extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control (L2624) provided October 
23, 2020. 
 
You asked the Plan to pay for the orthoses. You say that you have attached all of the supporting documentation. 
Please reprocess the claim. The Plan denied your request. The Plan says there is no clinical documentation to 
support the medical necessity of the requested orthosis. 
 
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 orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  
 
Our physician reviewer found in this case, there is no documentation of a physical exam of the right hip and no 
documentation of the completion or results of imaging of the hip. There is no clinical documentation of hip 
pain or signs and symptoms to support the diagnosis and requested DME. The review has determined that the 
requested item at issue in this case is not medically reasonable or necessary.
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for a prefabricated hip orthosis (L1686) and addition to lower extremity, pelvic control, hip joint, 
adjustable flexion, extension, abduction control (L2624) provided October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76942) provided on May 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 76942 
is a column II code to column I code 76937. 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 the services (76942) provided on May 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 19, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's 
attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says criteria is not met for inpatient hospital admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record does not document that the treating physician has a reasonable 
expectation of a length of stay spanning 2 or more midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve CT scan of thoracic spine. 
 
You asked the Plan to pre-approve the CT scan. You say that this should be covered because you have massive 
pain rated as 9/10 and you cannot take it anymore. The Plan denied your request. The Plan says Medicare says 
that you must have the following doctor's notes: doctor's notes that say why this test is needed. The Plan states 
they need to know the problem you are having, and the doctor's notes should say how this test will change your 
treatment. The Plan states the service is not necessary based on the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our 
physician reviewer found based on the presenting severe pain, magnetic resonance imaging (MRI) was 
appropriately approved to look for fracture or other acute condition. CT would not provide any significant 
additional information beyond the MRI that would change treatment at this time. Therefore, the CT 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 the CT scan have not been 
met. Therefore, we decided that the Plan does not have to pre-approve CT scan of thoracic spine.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on May 12, 2021. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for these tests is correct, because the documentation 
does not support that these tests were distinct because of being performed on a separate organ/structure. 
 
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 85014 is blood count, hematocrit. The CPT Code Manual 
definition of code 85018 is blood count, hemoglobin. The CPT Code Manual definition of code 85049 is blood 
count, platelet, automated. The CPT Code Manual definition of code 85027 is blood count, complete (CBC), 
automated. 
 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 lab tests. Our reviewer says that these codes do not meet the 
Medicare criteria for payment. Our reviewer found the laboratory report does not support these tests with 
modifier -XS (separate service that is distinct because it was performed on a separate organ/structure). 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on May 12, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 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 documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the MSH2 gene analysis coded 81295 and the MSH6 gene 
analysis coded 81298 provided on December 30, 2020. 
 
You asked the Plan to pay for the MSH2 gene analysis and the MSH6 gene analysis. 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 
separately payable. 
 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 81295 
for the MSH2 gene analysis is a column II code to column I code 81432. Additionally, we have confirmed that 
code 81298 for the MSH6 gene analysis is a column II code to column I code 81432. 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 the MSH2 gene analysis coded 
81295 and the MSH6 gene analysis coded 81298 provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or 
established patient (D0180) provided July 7, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal exam. You say that you were not asked or told 
about the service so you don't feel you should have to pay the bill. The Plan denied your request. The Plan says 
this service is not covered under your benefits. 
 
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 pay for the 
comprehensive periodontal evaluation - new or established patient (D0180) provided July 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) 
you received on March 8, 2021. 
 
You asked the Plan to waive the copayment for the TTE. You say that you thought this test was part of your 
wellness program. The Plan denied your request. The Plan says you were charged this copayment correctly. 
The Plan says that because the allowed amount for this test ($99.58) is less than your copayment obligation, 
you are responsible for the full allowed 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 $110 
copayment for radiological diagnostic services.  
 
Your Evidence of Coverage states that separate cost sharing applies for diagnostic tests performed as part of an annual wellness visit or annual physical. You have been asked to pay a $110 copayment for the TTE. The TTE 
falls within the radiological diagnostic services 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 the transthoracic echocardiography (TTE) you received on March 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fasenra. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fasenra.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 the enrollee meets the criteria for 
admission to an LTACH and would benefit from the transfer. The Plan denied your request. The Plan says the 
criteria for admission to an LTACH are not met. The enrollee is receiving appropriate treatment in the current 
acute care hospital; a transfer to an LTACH would not provide a clinical advantage. The requested LTACH 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case.  
 Our physician reviewer found there is no documentation provided indicating medical necessity for the 
admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 26, 2021.
You asked the Plan to waive the copayment for the ambulance transport. You say that the hospital specifically told you they would not use an ambulance to transport your father. You say you did not authorize the service and should not be responsible for the bill. 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 $150 copayment for each one-way ambulance trip. You have been asked to pay a $150 copayment for the ambulance transport. Ambulance transport falls within the Ambulance Services 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 the ambulance transport provided on January 26, 2021.