Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage of continuous positive airway 
pressure (CPAP) device E0601, humidifier, heated, used with positive airway pressure device (E0562). 
 
You asked the Plan to pre-approve the CPAP device. You say that you do use the CPAP, but you are awake 
when using it because of the fear of dryness you get when using it while sleeping. The Plan denied your 
request. The Plan says that the available medical records do not show adequate adherence with use of the 
device as is required by Medicare coverage criteria. 
 
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 CPAP device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the enrollee has 
met the requirements listed in the LCD for Medicare coverage. The records document 3% compliance with use 
of the CPAP for at least 4 hours per night during a consecutive 30-day period. Adherence to therapy is defined 
as use of CPAP =4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during 
the first three (3) months of initial usage. 
 
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 CPAP device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued coverage of continuous positive airway pressure (CPAP) device E0601, 
humidifier, heated, used with positive airway pressure device (E0562).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation (A0100). 
 
You asked the Plan to pre-approve additional trips. You say that the enrollee requires treatment 3 times per 
week. You say that the enrollee does not have transportation, economic, or family resources. You say that the 
enrollees municipality does not provide transportation services. You also say that the enrollee needs additional 
trips to be approved. The Plan denied your request. The Plan says addition trips beyond the 36 allowed per year 
are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation (A0100).
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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have 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 that on review of the available records, you have been diagnosed with debility 
and functional dependence as described above, does not meet Medicare coverage criteria for IRF admission. 
You are medically stable with no new and acute medical conditions and do not need physical medicine and 
rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. No acute rehab nursing needs identified or 
documented in the record. You do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach in an IRF. Your care needs can be met safely and 
provided at a lower intensity and alternate setting such as in an SNF. 
 
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 TERT promoter testing (81345) provided December 6, 2021. 
 You asked the Plan to pay for laboratory services. You say that please see the attached medical necessity 
documents. The signed physician order validates the Dermtech test was ordered. The Plan denied your request. 
The Plan says this service cannot be paid separately. 
 
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 81345 
is a column II code to column I code 0089U. 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 TERT promoter testing (81345) provided December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 testing. 
 
You asked the Plan to pre-approve the testing. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA1 and BRCA2 genetic testing is considered 
medically necessary for a beneficiary with a current diagnosis or a personal history of a cancer associated with 
the BRCA mutation who meets one or more of the criteria found in the most recent version of the NCCN 
guidelines. 
 
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 testing. Our reviewer says that the 
requested testing is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee does not have a personal history of cancer. The requested testing is not medically reasonable or 
necessary according to the coverage criteria established in the LCD. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve BRCA1 and BRCA2 testing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax and 
abdomen/pelvis. 
 
You asked the Plan to pre-approve the CT imaging. You say that this imaging is medically necessary. The Plan 
denied your request. The Plan says there is no clinical rationale given to support the need for this imaging. 
 
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 imaging. Our reviewer says that 
the requested imaging is not considered medically necessary at this time. Our physician reviewer found the 
enrollee is a female with a history of breast cancer, pancytopenia, and cirrhosis of the liver. There is no specific 
clinical rationale for the requested CT scans of the thorax and abdomen/pelvis. 
The review has determined that the requested CT scans are not medically necessary or reasonable. 
 
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the thorax and abdomen/pelvis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 22, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on March 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Trivisc (J7329). 
 
You asked the Plan to pre-approve Trivisc. You say that the requested drug is a necessity for your care. The 
Plan denied your request. The Plan says step therapy rules for the requested drug have not been met. 
 
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 Trivisc. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Euflexxa, Durolane, Supartz-FX, and Gelsyn-3 before they will approve the requested 
drug. The requested drug is a new start for you. The provided records do not indicate that you have tried and 
failed the Plan's preferred step-one alternatives. The record does not indicate that you have a contraindication 
to, or would have an adverse effect from, the Plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trivisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Trivisc (J7329).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic or therapeutic injection. 
 
You asked the Plan to pre-approve a diagnostic or therapeutic injection. 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 follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 diagnostic or therapeutic injection. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has 
focal pain rather than radicular pain. Therefore, she does not meet the criteria of the LCD. The requested 
procedure 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 a diagnostic or therapeutic injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a diagnostic or therapeutic injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) testing provided on 
November 18, 2021, billed with code 81455. 
 
You asked the Plan to pay for the F1Heme testing as billed. You say that this is a covered test and has proven 
clinical utility. The Plan denied your request. The Plan says the code used is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the 
medical necessity of Genomic Sequential Analyses panels for patients with AML, MPN, and MDS for a 
limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 
81450 may be covered by Medicare.   
We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes 
analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 
51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the 
entire panel exceeds what is covered under these provisions. Therefore, we decided that the Plan does not have 
to pay for the FoundationOne Heme (F1Heme) testing provided on November 18, 2021, billed with code 
81455.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that the enrollee is unable to take other medications. The 
Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's 
prescription drug plan. 
 
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 Gemtesa.  
 Benefits for Gemtesa 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 long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that it is not medically safe for the enrollee to go to the LTACH at 
this time. 
 
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. The patient 
appears to be improving on current treatment but is still somewhat unstable and should only require short-term 
acute care services including wound care, pain control, and physical therapy that can safely be administered at 
the current facility until appropriate for a lower level of care. The patient does not require services at the 
LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1, BRCA2 (breast cancer 1 and 2) (81162). 
 
You asked the Plan to pre-approve the genetic testing. You say that it is unreasonable to have to wait until 
metastasis is present to perform the genetic study. Medical records are on file with all tests and studies 
performed over the past few years. The Plan denied your request. The Plan says there has been no clinical 
records provided to support that the study is reasonable and medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 BRCA1, BRCA2 (breast cancer 1 and 
2) (81162). have been met. In this case, medical records were required to support that the requested service is 
medically necessary. The records show that the Plan made multiple attempts to contact the provider to request 
the needed medical records without success. Therefore, we decided that the Plan does not have to pre-approve BRCA1, BRCA2 (breast cancer 1 and 2) 
(81162).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from April 4, 2021, through 
April 9, 2021, at DRG 871. 
 
You asked the Plan to pay for the inpatient services at DRG 871. You say that the medical records support the 
diagnosis of sepsis and acute respiratory failure. You say that the documents should be reviewed, and the claim 
approved for payment as originally coded. The Plan denied your request. The Plan says the clinical evidence 
does not support assignment of code J96.01. 
 
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 diagnosis code J96.01 defined as acute respiratory 
failure, not elsewhere classified Type 2 with hypercapnia. 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 at DRG 871. Our reviewer says that the documentation does not support the 
diagnosis code J96.01. Our physician reviewer found that the initial laboratory data indicated a creatinine of 
1.16 and a platelet count of 208. While an elevated total bilirubin of 1.2 on presentation was noted, the total 
bilirubin decreased to 0.6 following intravenous fluid administration in the emergency room.  
 
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 provided from April 4, 2021, through April 9, 2021, at DRG 871.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 these services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on October 18, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing 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 CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on October 18, 2021.