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

 
We decided that the Plan does not have to pay for the panel testing provided on February 16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports medical necessity. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the panel testing provided on February 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) assessment using 
the Lymphedema Index (L-Dex) testing device (93702). 
 
You asked the Plan to pre-approve a bioimpedance spectroscopy (BIS) assessment using the Lymphedema 
Index (L-Dex) testing device. You say that the services are medically necessary. The Plan denied your request. 
The Plan says the services 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 a bioimpedance spectroscopy (BIS) 
assessment using the Lymphedema Index (L-Dex) testing device. Our reviewer says that the requested services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found BIS testing is 
not supported in the current literature as the best method to monitor for lymphedema due to its high false negatives and is not standard practice in this clinical setting when other methods such as lymphogram is more 
sensitive of a test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bioimpedance spectroscopy (BIS) assessment using the Lymphedema Index 
(L-Dex) testing device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
bioimpedance spectroscopy (BIS) assessment using the Lymphedema Index (L-Dex) testing device (93702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT) (77401, 77387, 
77290, 77300). 
 
You asked the Plan to pre-approve IGRT. You say that the enrollee has many underlying medical issues that 
prevent from having surgical excision of the tumor. You also say that the enrollee is prone to surgical site 
infection. The Plan denied your request. The Plan says the requested services 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 IGRT. Our reviewer says that the 
requested IGRT is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation does not support that the requested IGRT is not required based on the 
community standard of care. Therefore, the reviewer found that the requested IGRT 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 IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image guided radiation therapy (IGRT) (77401, 77387, 77290, 77300).
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 you need close physician management and the 
wound care rehabilitation. You say you are a fall risk. The Plan denied your request. The Plan says the IRF care 
is not medically necessary, and your needs can be met at a lower level of care such as a skilled nursing facility. 
 
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 you are medically stable with no acute medical illness and do not need a physician's close supervision three times per week (at a minimum) for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. The record shows there are no recent medical illness or admission 
to a hospital documented except steady functional decline with a non -healing right foot ulcer. The record 
shows there are no acute nursing needs identified or documented. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says that based on Medicare guidelines, the IRF services you are requesting do 
not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the clinical documentation shows the enrollee has complex functional deficits (below the knee 
amputation is IRF compliant) and active medical comorbidities, thus the complexity of the enrollee's nursing, 
medical and rehabilitation needs would be expected to require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. Evaluating physical and occupational therapists both 
document that the enrollee would continue to benefit from high intensity therapy and tolerate three hours of 
therapy per day. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 January 3, 2022, billed with 
codes 81270, 81279 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and was 
ordered by the enrollee's treating physician. The Plan denied your request. The Plan says panel testing should 
be billed using one CPT code on the claim. 
 
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 
January 3, 2022, billed with codes 81270, 81279 and 81335.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377), harness (E2313), and 
electronic connection (E2311). We decided that the Plan does not have to pre-approve a foot extension 
(K0108), and inner liner (K0108).   
You asked the Plan to pre-approve an expandable controller (E2377), harness (E2313), electronic connection 
(E2311), foot extension (K0108), and inner liner (K0108).. You say that the items are medically necessary. The 
Plan says that the member does not need these items. 
 
We decided that the Plan has to pre-approve an expandable controller (E2377), harness (E2313), and 
electronic connection (E2311).  
 
The Plan follows Medicare rules. Medicare rules say that that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services 
include services to improve the functioning of a malformed body member. 
 
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 an expandable controller (E2377), 
harness (E2313), and electronic connection (E2311). Our reviewer says that the member needs these medical 
items. Our physician reviewer found the enrollee does not have strength to manage multiple switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage an expandable controller (E2377), harness (E2313), and electronic connection 
(E2311) have been met. Therefore, we decided that the Plan has to pre-approve an expandable controller 
(E2377), harness (E2313), and electronic connection (E2311).  
 
We also decided that the Plan does not have to pre-approve a foot extension (K0108), and inner liner 
(K0108). 
 
The Plan follows Medicare rules. Medicare rules say that Code E1012 includes all components of the leg rest, 
including fixed angle footplates and foot platforms. Adjustable angle footplates coded K0040 (ADJUSTABLE 
ANGLE FOOTPLATE, EACH) are separately payable when provided with leg rests coded as E1012. 
Wheelchair seat and back cushion codes are all-inclusive. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a foot extension (K0108), and inner liner (K0108). have not been met. Specifically, the foot plates 
cant be approved separately from the elevating leg rests and the seat liner cannot be separately approvable the 
components are included in the wheelchair seat. Therefore, we decided that the Plan does not have to pre-
approve a foot extension (K0108), and inner liner (K0108). 
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines, the IRF services requested do not meet the 
requirements for approval. 
 
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 documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Additionally, clinical documentation states that a skilled nursing facility was recommended 
after lumbar fusion thus there is no documentation to show that the enrollee would tolerate 15 hours of therapy 
per week. 
 
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: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for therapeutic repetitive transcranial magnetic stimulation (TMS) 
treatment provided on January 13, 2022. 
 
You asked the Plan to pay for TMS treatment. You say that the service was medically necessary and was 
authorized. The Plan denied your request. The Plan says that the Plan failed to provide a reconsideration 
determination within the required CMS timeframe. 
 
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 a Medicare or Plan rule to substantiate 
their denial. Therefore, we decided that the Plan has to pay for TMS treatment provided on January 13, 2022.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
zoledronic acid. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug. The reviewer also found that the documentation does 
not support that zoledronic acid would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minute man procedure (22840 and 22612). 
 
You asked the Plan to pre-approve a minute man procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the 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 a minute man procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there isn't sufficient high-quality evidence to support interspinous-interlaminar fusion 
surgery and the devices used for it at this time, particularly when the patient reported significant benefit with 
currently prescribed treatments. More research is needed to show safety and efficacy of the procedure and the 
devices. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a minute man procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a minute man procedure (22840 and 22612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transplant evaluation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve evaluation visit. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this provider is out-of-network with the Plan and the enrollee can 
be treated within the Plan network. 
 
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 
a transplant evaluation to be provided by an out-of-network (OON) provider.
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 December 16, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this testing was medically 
necessary. 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 
December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AlloMap molecular expression testing (81595) provided 
on June 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that AlloMap is a diagnostic test that helps 
physicians care for their heart transplant recipients. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 AlloMap molecular expression testing (81595) 
provided on June 6, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service November 8, 2021. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that these services 
were necessary and were reported appropriately. The Plan denied your request. The Plan says this code is 
included in the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service November 8, 2021.