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

 
We decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (e.g., hereditary 
hypercoagulability) gene analysis (81240). 
 
You asked the Plan to pre-approve F2 gene analysis. You say that this test is medically necessary. The Plan 
denied your request. The Plan says testing for the F2 gene is not considered to be clinically efficacious and 
therefore is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the F2 and F5 genetic tests are not considered to 
be clinically efficacious; therefore, testing is not medically necessary. Medicare rules say that items and 
services that are not medically necessary are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F2 gene analysis have not been met. Specifically, the rules say that testing for the F2 gene is not 
medically necessary. Therefore, we decided that the Plan does not have to pre-approve F2 (prothrombin, 
coagulation factor II) (e.g., hereditary hypercoagulability) gene analysis (81240).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF services in order to regain maximum 
function. The Plan denied your request. The Plan says the request 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
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 documentation shows that the enrollee has active medical comorbidities however 
there are no complex functional impairments specified thus the enrollee would not be expected to require 
intense therapy or interdisciplinary team management of rehabilitation in an IRF setting. 
 
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 FoundationOne CDx (F1CDx) (0037U) testing provided on 
March 23, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an approved test which was provided for a 
covered indication. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of F1CDx testing have 
not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) 
(0037U) testing provided on March 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 23, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the records support the separate services 
billed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pneumatic compressor to be provided by an out-of-network (OON) provider.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires or can tolerate this therapy on an intensive IRF level. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 Sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 Sensor. You say that the clinical information provided 
supports the need for the requested item. The Plan denied your request. The Plan says you are requesting a 
CGM product that does not meet Medicare's definition of durable medical equipment (DME) and, therefore, is 
not in a defined Medicare benefit category. 
 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 use insulin 
with at least three daily injections. In addition, the Freestyle Libre 3 is not listed as a product that is represented 
by code K0554. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 3 
Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 3 
Sensor.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a biventricular pacemaker (CRT-P). 
 
You asked the Plan to pre-approve a CRT-P. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that CRT will be considered medically 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 CRT-P. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found left ventricular size and function is normal 
on recent echocardiogram. The enrollee claims he is asymptomatic from heart rhythm standpoint but is instead 
limited by joint problems. Decreased exercise capacity on stress test is cited, but no evidence to confirm 
symptomatic bradycardia. As such, 2021 AHA/ACC guidelines do not recommend CRT-P. In summary, there 
is insufficient documentation to support the medical necessity for placement of a bi-ventricular pacemaker. 
 
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 CRT-P have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a biventricular pacemaker (CRT-P).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 that 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 found to be medically reasonable and necessary. Our physician reviewer found the 
documentation shows that you have complex functional impairments and active medical comorbidities thus the 
complexity of your nursing, medical and rehabilitation needs would require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Evaluating therapists recommend intense therapy in an 
IRF setting thus IRF criteria 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 heavy duty power wheelchair (K0801). 
 
You asked the Plan to pre-approve a power wheelchair. You say that your power wheelchair is your lifeline, 
and you are unable to do the repairs yourself. You use the arms to lift yourself up and with unstable arms you 
are afraid you will fall down while using the arms for support. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for a new power wheelchair as the records show that you were approved for 
your current power wheelchair in December 2018. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 The file shows that you have power wheelchair. The records show that the current power wheelchair was 
purchased in 2018 and has a lifetime of 5 years. power wheelchair serves the same purpose as a power 
wheelchair. Therefore, we decided that the Plan does not have to pre-approve a Group 1 heavy duty power 
wheelchair (K0801).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zostar (shingles) vaccine (90750) provided on February 
10, 2022. 
 
You asked the Plan to pay for the shingles vaccine. You say that you are being told that the brand of drug used 
for this shot is not covered. You say that you had zero say in what drug was used. You also say that this should 
be covered. The Plan denied your request. The Plan says the shingles vaccine is not covered under Medicare 
Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the Zostar (shingles) vaccine (90750) 
provided on February 10, 2022.  
 
Benefits for the shingles vaccine 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided February 2, 2022, to 
March 3, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that the claim and NOA must have the appropriate information 
for payment to be made. 
 
Review of the file shows that the final claim has the admission date of August 6, 2021. Per guidelines an NOA 
must be submitted with a from date that matches the admission date on the final home health claim. 
As the NOA was not submitted with the correct information, no payment can be made on this claim. Therefore, 
we decided that the Plan does not have to pay for the home health services provided February 2, 2022, to 
March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit (90832) provided on July 6, 2022. 
 
You asked the Plan to pay for the psychotherapy service. You say that the service was medically necessary. 
The Plan denied your request. The Plan says there is no documentation that a psychiatric disorder currently 
exists, and there is lack of documentation of active symptoms either through observation or testing. 
 
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 psychotherapy service. Our reviewer 
says that the requested psychotherapy service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not indicate the enrollee was showing any 
symptoms of their illness. Therefore, the reviewer found that the service in this case was 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 psychotherapy service have not been met. Therefore, we decided that the 
Plan does not have to pay for the psychotherapy visit (90832) provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the injections (96372) provided from 
March 9, 2022, to June 28, 2022. 
 
You asked the Plan to pay an additional amount for the injections. You say that you feel you should be paying 
a 10% coinsurance instead of a copayment for Medicare Part B Prescription Drug injection. You also say that it 
was rendered by a nurse and not your primary care physician. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
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 $10 
copayment when rendered by a primary care provider (PCP) for Medicare Part B Prescription Drugs.  
 You have been asked to pay less than the standard $10 copayment per visit. The total amount you owe is 
$64.84. These services fall within the Medicare Part B Prescription Drugs 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 pay an additional amount for the injections (96372) provided from March 9, 2022, to June 28, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78830 billed for date of service June 28, 
2022. 
 
You asked the Plan to pay for procedure code 78830. The Plan denied your request. The Plan says payment for 
code 78830 is bundled into payment for code 78832. 
 
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 78830 
is a column II code to column I code 78832 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 78830 billed for date of service June 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 72125 and 70450 billed for services 
provided on May 25, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on July 21, 2022. A comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed /services were provided twice on the same date.  Based on this information, we decided that the Medicare rules for the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 72125 and 70450 billed for 
services provided on May 25, 2022.