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

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve the requested neuropsychological testing. You say that it is felt that this 
testing is needed to determine a diagnosis and treatment plan. The Plan denied your request. The Plan says 
Neuropsychological Testing does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that Neuropsychological Testing is intended to diagnose 
and characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. 
The Medicare rules section of this decision lists covered indications.  
 
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 requested neuropsychological 
testing. Our reviewer says that the requested neuropsychological testing is not shown to be medically reasonable and necessary. Our physician reviewer found Based on review the records provided, this patient has 
had difficulty with Dementia, Depression and Anxiety. Documentation shows this patient be pleasant able to 
tolerate the medication without difficulty. The patients documentation shows the patients neurologic exam to 
be oriented to time place and person. The patient had normal language function including naming, repetition 
and ability to follow multistage commands. Utilizing the criteria from LCD L33632 that this testing is intended 
to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly on or 
indirectly on the brain including detection of neurologic disease based on quantitative assessment of 
neurocognitive abilities, differential diagnosis between psychogenic and neurogenic syndromes, delineation of 
neurocognitive effects of central nervous system disorders, neurocognitive monitoring of recovery or 
progression of central nervous system disorders or assessment of neurocognitive function for the formulation of 
rehabilitation and/or management strategies among individuals with neuropsychiatric disorders, this patient 
does not meet the criteria as a patient is not showing severity of symptoms that would warrant this type of 
diagnostic treatment and is therefore not appear medically necessary or reasonable. The neuropsychological 
testing as outlined documentation is unclear what questions needed to be answered by this testing. 
 
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 requested neuropsychological testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve neuropsychological testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483, 80307) provided on March 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. 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 lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483, 80307) provided on March 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided to the enrollee on July 2, 
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 Medicare continues to cover the enrollee through the end of the month when the beneficiary 
revokes or is discharged alive. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for psychotherapy services provided to the enrollee on July 2, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OmniSeq testing. 
 
You asked the Plan to pre-approve the requested testing. You say that the analysis is critical to determining the 
appropriate treatment plan for the enrollee. The Plan denied your request. The Plan says the test goes beyond 
the comprehensive genomic profiling and includes immune profiling 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 pre-approve the requested testing. Our physician 
reviewer found that the enrollee has stage IV squamous cell carcinoma of unknown primary origin. Surgical 
pathology supported a diagnosis of well to moderately differentiated squamous cell carcinoma, HPV 
associated. The available documentation does not support the OmniSeq Insight Panel testing results will impact 
the clinical management of the enrollee in this case. The documentation does not support that the OmniSeq 
testing meets, but does not exceed, the enrollees medical need, and is at least as beneficial as existing and 
available medically appropriate alternatives. The available documentation does not support the OmniSeq 
Insight Panel testing is medically reasonable and necessary for the enrollee in this case. 
 
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 requested testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve OmniSeq testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown on tooth #29 (CPT code D2740). 
 
You asked the Plan to pre-approve the dental services. You say that the service is necessary. The Plan denied 
your request. The Plan says this exceeds the maximum count allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Our records show that these 
services were received on February 05, 2020. These services were paid on October 16, 2020. The plan does not 
allow for these services more than once every five plan years. Therefore, we decided that the Plan does not 
have to pre-approve the crown on tooth #29 (CPT code D2740).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four (4) HH SN services (CPT code G0299 x 4). 
 
You asked the Plan to pre-approve the HH SN services. You say that the services are necessary. The Plan 
denied your request. The Plan says the enrollee's records do not support the need for a skilled nurse to make 
more visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 HH SN services. Our physician 
reviewer found the health plans denial should be upheld. The enrollee does not have documented skilled 
nursing needs. As such, the requested, ongoing, HH SN services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the HH SN services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four (4) HH SN services (CPT code G0299 x 4).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an excision (49203) provided on October 25, 2021. 
 
You asked the Plan to pay for an excision. You say that this was medically necessary. The Plan denied your 
request. The Plan says this code is included in code 44130. 
 
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 49203 is excision or destruction, open, intra-abdominal 
tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary 
tumors; largest tumor 5 cm diameter or less. 
 
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 an excision. Our reviewer says that this code is not supported 
in the records. Our reviewer found this procedure would be inclusive to CPT 44130, enteroenterostomy, 
anastomosis of intestine, with or without cutaneous enterostomy (separate procedure), as it was performed in 
same anatomical area, through same incision. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an excision have not been met. Therefore, we decided that the Plan does not 
have to pay for an excision (49203) provided on October 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy. 
 
You asked the Plan to pre-approve Wegovy. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this medication is the responsibility of your prescription drug plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Wegovy.  
 
Benefits for Wegovy 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, G0480) provided on July 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. 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 lab services have not been met.  Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample 
was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for lab services 
(80307, G0480) provided on July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81120, 81235, 81210, 81272) provided April 
27, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 81120, 81235, 81210, & 81272 is not supported in the medical record. Specifically, the 
claim was not billed with a valid primary diagnosis code for C34.11 listed as the secondary diagnosis code. 
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 lab services (81120, 81235, 81210, 81272) 
provided April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve the SI injection. You say that this is a medically necessary treatment. The 
Plan denied your request. The Plan says there is not sufficient evidence to support the need for this injection. 
 
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 SI injection. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is a lack of documentation of physical examination diagnostic testing for SI joint 
dysfunction, such as Yeoman's Patrick's and Gaeselen tests. Since these are not documented, at this point, the 
request is deemed 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 SI injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a diagnostic sacroiliac (SI) joint injection.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing services (81455) provided on November 17, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved based on the medical records. The Plan denied your request. The Plan says that there was no 
order for genetic testing made. 
 
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 denied coverage specifically stating that no order for 
genetic testing was made. However, this assertion has not been substantiated in the record. Despite the Plan 
confirming they made a phone call where the providers office confirmed testing was not ordered, there is no 
proof. Furthermore, there is a test order form filled out by the enrollees provider as well as relevant medical 
records from the provider as well.  Therefore, we decided that the Plan has to pay for the genetic testing 
services (81455) provided on November 17, 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: 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 are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do need physical and/or occupational therapy, there is no documentation of a need for and ability to tolerate an 
intensive 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that this was medically necessary testing. 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.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the office POS code. 
The records do not support that the sample was taken in an office setting. The documentation indicates that the 
sample was taken at a psychiatric residential facility. Therefore, we decided that the Plan does not have to pay 
for lab services provided on July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81185, 81286, 81400, 81413, 81414, 81442, 
81479) provided July 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  
 
We looked at the file and Medicare rules. The records do not show the test was ordered by the treating 
physician. 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 lab services (81185, 81286, 81400, 
81413, 81414, 81442, 81479) provided July 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from July 29, 2021, to 
August 1, 2021, as billed with Diagnosis Related Group (DRG) 064. 
 
You asked the Plan to pay for inpatient care billed with DRG 064. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 064 is not appropriate as the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical record. The 
Plan argues that DRG 065 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
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 inpatient care billed with DRG 064. Our 
reviewer says that the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found the enrollee presented to the hospital on July 29, 
2021, with confusion and weakness. At the time of admission, the enrollee was oriented to self and place. 
Neurology was consulted. The enrollee was noted to have an acute left middle cerebral artery infarction. The 
enrollee's presentation was explained by the stroke, and the diagnosis of metabolic encephalopathy is not 
supported in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 064 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from July 29, 2021, to August 1, 2021, as 
billed with Diagnosis Related Group (DRG) 064.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection (20610, 73130, 73564, 76942) provided July 13, 
2021. 
 
You asked the Plan to pay for the injection. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support the billed codes. 
 
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 codes 20610, 73130, 73564, & 76942 are not supported in the medical record. Specifically, 
the procedure report provide does not document procedure codes 20610, 73130, & 73564 being performed. 
Procedure code 76942 is inclusive to the primary procedure and not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we 
decided that the Plan does not have to pay for an injection (20610, 73130, 73564, 76942) provided July 13, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789, 80307, 80299, G0482) provided on 
December 8, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 had network providers available who could have provided the services at issue in this appeal. 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 lab services (83789, 80307, 80299, G0482) provided on December 8, 
2021 by an out-of-network (OON) provider.