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

 
We decided that the Plan does not have to pay for a molecular pathology procedure (MI Tumor Seek) (81479) 
provided on July 15, 2022.  
You asked the Plan to pay for MI Tumor Seek testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says the enrollee did not have recurrent, relapsed, refractory, metastatic or 
advanced stage III or IV cancer. There was no indication that the provider was seeking other treatment such as 
chemotherapy 
 
The Plan follows Medicare rules. Medicare rules say that NGS testing is covered for enrollees with either 
recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
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 MI Tumor Seek testing. Our reviewer says 
that the service does not meet criteria for coverage. Our physician reviewer found that the coverage criteria 
have not been met. The records do not show that the enrollee has recurrent, relapsed, refractory, metastatic, or 
advanced stage III or IV cancer as required for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MI Tumor Seek testing have not been met. Therefore, we decided that the Plan 
does not have to pay for a molecular pathology procedure (MI Tumor Seek) (81479) provided on July 15, 
2022.
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 you are requesting reconsideration of the denial of 
services for inpatient rehab for the enrollee. 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 nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service August 4, 
2022. 
 You asked the Plan to pay for procedure code 85060. You say that this service was necessary and was reported 
correctly. The Plan denied your request. The Plan says this service was not reported in accordance with 
Medicare billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85060 have not been met. Specifically, the record shows that this service was 
furnished to an enrollee in an outpatient hospital (Place of Service code 22) setting. Therefore, we decided that 
the Plan does not have to pay for procedure code 85060 billed for date of service August 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 7, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you are disputing the share 
cost. 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 $250 
copayment for Ambulance services. The Plan is only holding your responsible for $50, which is less than the 
contractual obligation.  
 
You have been asked to pay $50, which is less than the $250 copayment for ambulance services. This 
item/service falls within the Ambulance services benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for ambulance services provided on July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 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 home mechanical ventilator. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found this patient likely has 
COPD with chronic CO2 retention and may benefit from BiPAP with average volume-assured pressure support 
(AVAPS) during sleep as an outpatient. A ventilator is not needed to provide AVAPS and is not covered by 
Medicare 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 home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 15, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
September 15, 2022.
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 services the enrollee requires are not able to be 
met in a lower level of care. The Plan denied your request. The Plan says the enrollee could receive care in 
another setting. 
 
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 enrollee does not require the intensity of services provided at an IRF. The 
enrollees care needs can be met at a lower level of care such as in a skilled nursing facility or a sub-acute 
rehab. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient detoxification services to be provided by a 
facility not enrolled in the Medicare program. 
 
You asked the Plan to pre-approve inpatient detoxification services. You say that representatives of the Plan 
advised you that you would be able to obtain authorization for the requested services. The Plan denied your 
request. The Plan says the requested provider is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve inpatient detoxification services to 
be provided by a facility not enrolled in the Medicare program.  
 
Your complaint about receiving erroneous or incomplete information from representatives of the Plan is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
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 your therapists feel that the intensity of an IRF is 
needed to help you return home at your prior level of independence. The Plan denied your request. The Plan 
says the services you need can be provided safely in other settings. 
 
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve moderate conscious sedation. 
 
You asked the Plan to pre-approve moderate conscious sedation. You say that moderate conscious sedation is 
medically necessary because the epidural steroid injection is painful. The Plan denied your request. The Plan 
says there is no documentation that attempts to provide the epidural steroid injection without sedation was 
unsuccessful. 
 
The Plan follows Medicare rules. Medicare rules say that the use of Moderate or Deep Sedation, General 
Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these 
procedures and therefore not considered medically reasonable and 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 moderate conscious sedation. Our 
reviewer says that moderate conscious sedation is not medically necessary in this case. Our physician reviewer 
found that based on the medical records provided there is no documentation that the moderate conscious 
sedation at issue in this case meets all Medicare criteria for medically reasonable and necessary. As stated in 
the Local Coverage Determination (LCD): Epidural Steroid Injections for Pain Management - L39242: "Use of 
Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and therefore not considered medically reasonable and 
necessary. Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. In exceptional 
and unique cases, documentation must clearly establish the need for such sedation in the specific patient." The 
provided records is this case do not clearly establish the need for such sedation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of moderate conscious sedation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve moderate conscious sedation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF services are 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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee 
may have a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided 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 the IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper extremity prosthesis, not otherwise specified 
(L7499). 
 
You asked the Plan to pre-approve an upper extremity prosthesis. You say that this is the only prosthesis that 
can articulate the missing digits based on movements of the second digit. The Plan denied your request. The 
Plan says the request for a custom prosthetic finger prosthesis cannot be approved at this time by Medicare or 
your health plan. 
 
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 CPT code L7499 is not supported in the medical record. Specifically, the code does not match the 
item requested. The requested prosthesis cannot be covered as the incorrect code is used. Approval is subject to 
correct coding by your prosthetic provider. Based on this information, we decided that Medicare rules for 
coverage of an upper extremity prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an upper extremity prosthesis, not otherwise specified (L7499).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist/hand orthosis provided on October 4, 2022. 
 
You asked the Plan to pay for the wrist/hand orthosis. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the supporting documentation must include subjective and objective 
beneficiary specific information used for diagnosing, treating, or managing a clinical condition for which the 
DMEPOS is ordered. 
 
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 wrist/hand orthosis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a diagnosis of primary osteoarthritis of the left and right wrists.  
 The medical records provided support the diagnosis of primary osteoarthritis of the left and right wrists; 
however, the provided records do not document a wrist/hand orthosis as part of the treating provider's plan of 
care for the enrollee. Therefore, the item rendered is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the wrist/hand orthosis have not been met. Therefore, we decided that the Plan 
does not have to pay for the wrist/hand orthosis provided on October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is not 
medically necessary. The Plan denied your request. The Plan says a genicular nerve block is considered 
experimental /investigational. 
 
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 genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that this procedure is considered experimental/investigational and is the subject 
of ongoing clinical trials. Therefore, the request is deemed not 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for IRF 
services. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program.  While the enrollee may have a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided 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 IRF admission and services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the services (76641-LT, 76641-RT) provided on November 2, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the MUE value 
has been exceeded. 
 
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. The Plan argues that code 76641 has an MUE of 1, however, a CPT code search 
reveals that code 76641 has an MUE value of 2. Additionally, Medicare rules say that a bilateral diagnostic 
procedure may be reported with 1 unit of service with modifier RT on 1 claim line plus 1 unit of service 
and modifier LT on a second claim line, as was done in this case. Without supporting documentation, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (76641-LT, 
76641-RT) provided on November 2, 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.