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

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this ventilator is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 ventilator. Our reviewer says 
that the requested home ventilator is not medically reasonable and necessary. Our physician reviewer found a 
home ventilator is not medically necessary. This patient has a diagnosis of COPD and alpha-1 antitrypsin 
deficiency, with frequent exacerbations. However, the medical records do not include pulmonary function tests 
or an arterial blood gas documenting CO2 retention. Even if the patient had CO2 retention, Medicare does not cover a ventilator when used as bileval positive airway pressure (BiPAP) device. BiPAP with the average 
volume-assured pressure support (AVAPS) mode has not been tried and failed. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the DetermaRx molecular predictive classifier testing provided on 
October 11, 2021. 
 
You asked the Plan to pay for the DetermaRx testing. You say that this testing is a medically necessary test to 
allow for treatment planning. The Plan denied your request. The Plan says that the follow-up note does not 
specifically state that chemotherapy is being considered. 
 
The Plan follows Medicare rules. Medicare rules say that testing such as DetermaRx may be covered when the 
criteria listed in the Medicare rules section 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 pay for the DetermaRx testing. Our reviewer says 
that the documentation available supports that the criteria for the rendered testing have been met. Our physician 
reviewer found the records show that the enrollee has non-squamous NSCLC with a tumor of less than 5cm, 
and there are no positive lymph nodes. The enrollee is sufficiently healthy to tolerate chemotherapy, adjuvant 
platinum-containing chemotherapy is being considered for the enrollee, and that the test is ordered by a 
physician who is treating the patient for NSCLC to help in the decision of whether or not to recommend 
adjuvant chemotherapy. 
 
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 DetermaRx testing have been met. Therefore, we decided that the Plan has 
to pay for the DetermaRx molecular predictive classifier testing provided on October 11, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmic biometry by partial coherence 
interferometry with intraocular lens power calculation provided on October 18, 2021. 
 
You asked the Plan to waive the copayment for ophthalmic biometry by partial coherence interferometry with 
intraocular lens power calculation. The Plan denied your request. The Plan says the allowed amount for the 
procedure was $52.42. Since the allowed amount is less than the applicable cost share, the total allowed 
amount of $52.42 charged is the members responsibility. 
 
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 $65 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay less than the applicable $65 copayment for ophthalmic biometry by partial 
coherence interferometry with intraocular lens power calculation. The ophthalmic biometry by partial 
coherence interferometry with intraocular lens power calculation falls within the outpatient diagnostic tests and 
therapeutic services and supplies 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 
ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation provided on 
October 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can safely be received at a different setting, for example, home with home 
health, in residential care, or home with close follow-up with the doctor. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis.  He is medically stable and can receive further rehab services at a lower level of 
care.  Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee 
does not have any parental medication; complex wound care or nutrition given via a feeding tube. He is 
medically stable without any acute exacerbations of chronic medical problems. His physical function is at or 
near his baseline and he can receive services at a lower level of care.  Admission to a SNF for inpatient skilled 
rehab services 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar-sacral orthosis (L0648) for the enrollee. 
 
You asked the Plan to pre-approve the item. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has bilateral primary osteoarthritis of the knees and low back pain. Lumbar brace and knee brace were requested. It was reported that physical therapy, medication, injections, and rest were tried and 
ineffective for the back and knee pain. There were no prior lumbar surgeries or recent falls. The physical exam 
showed tenderness of the lumbar area, diffuse weakness without focal limitation, sensation grossly intact, slow 
gait, but upright and stable. There was no documentation of subjective or objective instability or recent or 
upcoming procedure which would warrant a lumbar brace for this patient which isn't appropriate for pain 
reduction. The documentation does not show the patient meeting LCD criteria. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lumbar-sacral orthosis (L0648) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on February 26, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 14301: 
 
Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm 
 
CPT 21936: 
 
Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; 5 cm or greater  
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found in terms of CPT 14301, the operative 
report does not include sufficient documentation to confirm an adjacent tissue transfer or rearrangement has 
been performed. The operative report describes a advancement flaps. There is a more appropriate code to report 
for this procedure. Therefore, CPT 14301 cannot be verified. In terms of CPT 21936, the operative report does 
not include sufficient documentation to confirm a tumor resection has been performed. The operative report 
describes excision of melanoma including margins. There is a more appropriate code to report for this 
procedure.  
 
We looked at this coder's review, the file, and Medicare rules. 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 surgical services provided to the enrollee on February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on April 15, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 30901 (1 unit) remains 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 30901 is "Control nasal hemorrhage, anterior, simple 
(limited cautery and/or packing) any method." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found based on the available clinical 
documentation, it appears that CPT 30901 was not rendered in this case. The enrollee reported spontaneous 
epistaxis at home; however, clinical documentation stated that upon arrival to the emergency department, the 
epistaxis had stopped. There was no documentation of limited cautery, packing, or other anteriorly directed 
procedural intervention to specifically halt the nosebleed. Therefore, the record does not support that CPT 30901 was rendered. 
 
We looked at this coder's review, the file, and Medicare rules. 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 surgical services provided to the enrollee on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from October 1, 2021, to 
December 10, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services were rendered by a licensed 
acupuncturist, not a physician. The file does not show that this provider is supervised by any physician, PA, or 
NP/CNS. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided from 
October 1, 2021, to December 10, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, emergency transport  
(A0429, A0425) provided on September 5, 2021. 
 
You asked the Plan to pay for ambulance service, basic life support, emergency transport. You say that the 
claim was billed with the pickup zip code in boxes 39 and 80. The Plan denied your request. The Plan says that 
the claim was processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided the exact reason for the claim denial and 
the Plans rules for their denial. Additionally, the claim in the case file does show the pickup zip code in boxes 
39 and 80. Therefore, we decided that the Plan has to pay for ambulance service, basic life support, emergency 
transport (A0429, A0425) provided on September 5, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on November 5, 2021. 
 
You asked the Plan to pay for ophthalmological services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for ophthalmological services provided on November 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 services. Our reviewer says that the 
requested continuation of services is not medically reasonable or necessary. Our physician reviewer found at 
the time of admission, the enrollee required skilled rehabilitation services to improve function due to weakness 
and deconditioning. There were no skilled nursing needs. As of 4/6/22, the enrollee did not require any skilled 
nursing or rehab services on a daily basis.  He was not expected to make measurable gains within a reasonable 
and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of 
daily living (ADLs). The enrollee did not require skilled therapy to establish a safe and effective maintenance 
program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF 
level of care as of 4/6/22. The enrollee did not have any parental medications, complex wound care or nutrition 
given via a feeding tube. The enrollee received skilled care and improved; however, his functional 
improvement had plateaued by 4/6/22 and he did not require any further inpatient skilled rehab 
services. Function was at or near his prior level of function and he could be discharged to a lower level of care 
for further services.  As of 4/6/22, the enrollee required custodial 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic testing panel provided on 
August 25, 2021. 
 
You asked the Plan to pay for the GeneSight Psychotropic testing panel. You say that this is a Medicare-
covered test. The Plan denied your request. The Plan says there is not sufficient evidence to support this 
service.  
The Plan must follow Medicare rules. Medicare rules say that combinatorial PGx tests, such as GeneSight, are 
not clearly shown to be more beneficial in drug selection than usual prescribing methods. Based on this 
information, we decided that Medicare rules for coverage of the GeneSight Psychotropic testing panel have not 
been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic testing 
panel provided on August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided to the enrollee on October 
11, 2021. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the Tempus gene panel testing is only indicated for certain types of non-small cell lung cancer and 
metastatic colorectal cancer. There must be documentation that the testing is expected to influence treatment of 
the condition toward which the testing is directed.  
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 pay for the Tempus gene panel provided to the enrollee on October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0483) provided to the enrollee on 
October 27, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records only show that eleven drug classes were counted. 
 
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  is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the provided records did not clearly 
show that 22 or more drug classes were tested in this case. It appears that only 11 drug classes were tested on 
10/27/21. Additionally, the records did not show that it was reasonable to test 22 or more drug classes. There 
was no report suggesting possible drug abuse, misuse, or other medications used not listed in the above 
medication list that would warrant including in the definitive drug testing. 
 
We looked at this coder's review, the file, and Medicare rules. 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 drug testing services (G0483) provided to the enrollee on October 27, 2021.