Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on February 5, 2022. 
 
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 procedure code 00910 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 00910 is anesthesia for transurethral procedures 
(including urethrocystoscopy); not otherwise specified. 
 
We find that CPT code 00910 is not supported in the medical record. Specifically, there are no records for the 
second anesthesia service. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services 
rendered on February 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat magnetic resonance imaging (MRI) of lumbar 
spine (72158). 
 
You asked the Plan to pre-approve a repeat MRI. You say that the physician that the physician the enrollee is 
being referred to requires an MRI before scheduling an appointment. The Plan denied your request. The Plan 
says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 a repeat MRI. Our reviewer says that 
the requested repeat MRI is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate there were significant change in physical findings to show MRI findings 
would be different enough to warrant repeat MRI at this time. Therefore, the reviewer found that the request for 
a repeat MRI 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 a repeat MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat magnetic resonance imaging (MRI) of lumbar spine (72158).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 12 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 12 additional PT visits. You say that the enrollee has had a significant 
decline in independence with all areas of living. The Plan denied your request. The Plan says that the requested 
services are medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 12 additional PT visits. Our reviewer 
says that the requested 12 additional PT visits are medically necessary. Our physician reviewer found the 
provided clinical documentation shows that the enrollee has not met all physical therapy goals. The reviewer 
found that the enrollee still requires physical assistance with mobility tasks with trial of different assistive 
devices which would require the skill of a professional therapist. Therefore, the reviewer found that 12 
additional physical therapy sessions is medically reasonable and 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 12 additional PT visits have been met. Therefore, we decided that the Plan has 
to pre-approve 12 additional physical therapy (PT) visits.  
 
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 diabetes hereditary risk assessment provided on 
September 10, 2021. 
You asked the Plan to pay for the testing services. You say that the medical records support medical necessity. 
The Plan denied your request. The Plan says the clinical effectiveness has not been demonstrated. 
 
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 was requested for screening purposes. Medicare does not cover this testing for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the diabetes hereditary risk 
assessment provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on December 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not 
include a signed physician order or signed lab requisition. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on December 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets Medicare criteria for 
LTACH admission, and that the enrollee's ongoing medical care warrants it. The Plan denied your request. The 
Plan says the level of care given at the LTACH setting is more than the enrollee's medical conditions needs and 
that the enrollee does not meet the guidelines for long term acute care services. The enrollee can receive care in 
another setting like home health services. 
 
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 that the enrollee appears to be a candidate for short term acute care hospital 
(STACH) for the procedure and immediate post-op care. It is not known how the enrollee will respond to the 
surgery or what wound care needs and duration will be needed until after the surgery. The enrollee does not 
require services at the LTACH that would not be available at an STACH. 
 There are no services at the LTACH that the enrollee currently requires that are not already available and 
covered at an STACH. Admission to LTACH is not medically necessary as it would not be clinically 
advantageous at this time based on current needs. 
 
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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have obesity-hypoventilation 
syndrome. The appropriate treatment is cpap or bipap. Medicare does not cover a home ventilator for this 
diagnosis.  Failure to completely normalize PaCO2 in the hospital while acutely ill does not constitute failure 
of bipap for home use. Medicare does not cover a home ventilator when used as bipap. 
 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
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 had a tumor removed from the bladder, and have 
been in the hospital for two weeks. You also say that you need rehabilitation to regain strength. The Plan 
denied your request. The Plan says the record shows that the enrollee does not meet Medicare guidelines for 
services in an IRF. 
 
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 patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient's medical status does not require intensive physician and nursing oversight 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, lenses, and progressive lenses provided on 
December 16, 2020. 
 
You asked the Plan to pay for the frames, lenses, and progressive lenses. You say that you would like to appeal 
this denial. The Plan denied your request. The Plan says this claim was received over a year after services were 
rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the frames, lenses, and progressive lenses was not filed until December 30, 
2021. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for the frames, lenses, and progressive lenses 
provided on December 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on November 22, 2021. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the 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 the drug 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 the drug testing provided on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on February 16, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene.  
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. 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 FANCC genetic testing provided on 
February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 10, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation 
does not contain a lab requisition for the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a lab requisition for 22 or more 
drug classes. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on 
March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that the enrollee is diabetic and 
needs to monitor and view her sugar levels. This particular monitor allows her to view as many times as 
needed. The Plan denied your request. The Plan says the enrollee does not meet prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day and use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre 2 CGM sensor have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM) sensor (K0553).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for 
lymphedema assessment(s) (93704 x 4). 
 
You asked the Plan to pre-approve BIS. You say that the services are medically necessary to determine if the 
enrollee has lymphedema. The Plan denied your request. The Plan says that experimental and investigational 
procedures are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve BIS. Our reviewer says that the 
requested bioimpedance spectroscopies are considered medically reasonable and necessary in this case. Our 
physician reviewer found bioimpedance spectroscopy for breast cancer related lymphedema assessment has 
become a standard of care for prevention and treatment. The reviewer found that the highest risk of developing 
lymphedema is within the first three years of treatment. The reviewer found that early intervention can limit 
progression of disease, and high-risk patients should be followed closely in this period. The reviewer found that 
the enrollee in this case is suspected to have subclinical lymphedema. Therefore, the reviewer found that the 
requested services are reasonable and 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 BIS have been met. Therefore, we decided that the Plan has to pre-approve 
bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s) (93704 x 4).  
 
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 lab testing services provided on February 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that the enrollee meets the requirements for coverage. 
The Plan denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation.  
 
We find that the gene panel testing is not supported in the medical record. There are insufficient medical 
records from the treating physician to show how the testing services would impact clinical management. The 
records do not clearly document an intent for the testing to be done. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab testing services provided on February 8, 
2022.
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 exceeds the Medicare 
guidelines for LTACH admission. The Plan denied your request. The Plan says it is not safe for the enrollee to 
leave the hospital and that they are receiving the proper care they need in the hospital without a need to transfer 
to the LTACH. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care hospital services that can safely be completed at the current facility until a 
lower level of care is appropriate as her mental status improves and feeding status improves. The enrollee does 
not require services at the LTACH that are not already available at the current facility.  
 
  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous at 
this time. Completion of treatment at the current facility is recommended. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 17, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 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. 
 
Review of the file shows that the documentation does not support that this testing would be helpful in the 
therapeutic decision making of the enrollees treatment. The genetic testing at issue in this appeal 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 genetic testing provided on December 17, 
2021.