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

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD) with cough and difficulty raising secretions. There is no diagnosis of cystic 
fibrosis, bronchiectasis, or neuromuscular disease. There is inadequate evidence of benefit of HFCWOD in the treatment of COPD. The services are therefore not reasonable or 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 a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 31, 2022, billed with 
codes 87481, 87496, 87500, 87511, 87529, 87532, 87640, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were provided in good faith 
and were medically necessary. The Plan denied your request. The Plan says panel testing should be billed using 
one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 31, 2022, billed with codes 87481, 87496, 87500, 87511, 87529, 87532, 87640, 87653, 87798, and 
87801.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, 
DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and 
full duplication/deletion analysis (i.e., detection of large gene rearrangements) (81162). 
 
You asked the Plan to pre-approve the Invitae BRCA1 and BRCA gene analysis. You say that the denial says 
you never had cancer, but you had cervical cancer in 1992 or 1993. The Plan denied your request. The Plan 
says that the enrollee does not meet the required criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Invitae BRCA1 and BRCA gene 
analysis. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a history of cervical cancer and a mother 
and maternal grandmother with breast cancer and a maternal grandfather with prostate cancer. The LCD is met 
as the enrollee has history of cancer and is at risk by virtue of the 3 relatives discussed above with prostate 
cancer and breast cancer. 
 
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 Invitae BRCA1 and BRCA gene analysis have been met. Therefore, we 
decided that the Plan has to pre-approve BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA 
repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full 
duplication/deletion analysis (i.e., detection of large gene rearrangements) (81162).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service January 25, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a physical therapy evaluation, high complexity (97163) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a physical therapy evaluation. You say that the therapist at this facility will 
be working together with your physician to specify the type of care that you require and the type of care that is 
safe for your hypermobility diagnosis. The Plan denied your request. The Plan says you must use network 
providers to get your medical care and services. Medically necessary care is available in network. 
 
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 physical therapy evaluation, high complexity (97163) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service June 6, 2022. 
 
You asked the Plan to pay for procedure code 81345. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 81345 is bundled into 
payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 81345 billed for date of service June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital observation service, per hour provided May 14, 
2022, to May 18, 2022. 
 
You asked the Plan to pay for the hospital observation service, per hour. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
In this case, the CPT Code Manual definition of code G0378 is hospital observation service, per hour. 
 
We find that CPT code G0378 is not supported in the medical record. Specifically, this code is not allowed to 
be reported more than once per claim. This code is reported more than nonce on this claim/bill type. The claim 
is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the hospital observation service, per hour have not been met. Therefore, we decided that the Plan does not have to pay for 
the hospital observation service, per hour provided May 14, 2022, to May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure, targeted 
genomic sequencing (81479) provided March 30, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the biomarker testing services should be 
covered because the in-network physician ordered these services and determined the resulted of these services 
were medically necessary to provide the best care for the enrollee. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria for the requested test. The records show that there was no evidence of 
cancer that was recurrent, relapsed, refractory, metastatic or advanced. 
 
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 laboratory services. 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 invasive ductal carcinoma of the left female breast, 
estrogen receptor positive. The coverage criteria established by NCD 90.2 have not been met in this case, as the 
laboratory test does not have FDA approval or clearance as a companion in vitro diagnostic, and an FDA-
approved or FDA-cleared indication for use in the enrollee's cancer. Additionally, it has not been demonstrated 
that all of test results may become clinically actionable. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the unlisted molecular pathology procedure, targeted genomic sequencing (81479) 
provided March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (E0973, E2365, K0823, E1028). 
 
You asked the Plan to pre-approve power wheelchair. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says the power wheelchair is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says 
that the power wheelchair is not medically necessary. Our physician reviewer found based on the records 
provided, the enrollee has adequate strength in upper and lower extremities to manage a manual wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair (E0973, E2365, K0823, E1028).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has low back pain. The 
records show multiple plausible pathologic sources of significant pain generation. The back pain, leg tightness, 
decreased spinal motion, and axial pain with the slump test are all non-specific to any pathologic entities. The 
documentation is lacking regarding any evidenced findings supportive of the spinal vertebral bodies as being 
the overwhelming primary generators of the enrollees chronic persistent pain. The Intracept is not reasonable 
or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition supplies billed for dates of service 
July 1, 2022, to July 7, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says proof of delivery 
was not provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain proof of delivery or relevant medical records which support medical necessity for 
the supplies provided in this case. Based on this information, we decided that the Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the parenteral nutrition 
supplies billed for dates of service July 1, 2022, to July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the Medicare rules 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 the home ventilator. Our physician 
reviewer found there is no documentation that bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) was tried and failed as an outpatient. Medicare does not cover a home 
ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 9, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contract between 
the laboratory and the dialysis facility for payment. The Plan denied your request. The Plan says Medicare does 
not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services billed for date of service January 2, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says this claim is a 
duplicate. 
 
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.  
 
 
 
 The file shows that procedure codes 71045-26 and 71045-26-76 was billed. We looked at the file and Medicare 
rules. The file shows that code 71045-26 was reimbursed by the Plan on February 9, 2022, and code 71045-26-
76 was reimbursed by the Plan on June 16, 2022. 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 the 
radiology services billed for date of service January 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air immersion therapy mattress (E1399). 
 
You asked the Plan to pre-approve an air immersion therapy mattress. You say that you disagree with the 
denial. The Plan denied your request. The Plan says since the requested mattress serves the same purpose as 
equipment already available to the enrollee, it is not considered reasonable and necessary. 
 
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 the enrollee has an air-fluidized pressure reducing therapy bed. This bed serves the same 
purpose as an air immersion therapy mattress. Therefore, we decided that the Plan does not have to pre-approve 
an air immersion therapy mattress (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056 x 5), abutment 
supported crown (D6058 x 5) and pontic (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted when the Plan authorized D6056, D6058 
and D6245 to their benefit limits. Therefore, we decided that the Plan does not have to pre-approve a 
prefabricated abutment (D6056 x 5), abutment supported crown (D6058 x 5) and pontic (D6245).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 80076 and 84443. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 83718 and 83721.  
 
You asked the Plan to pay for laboratory services provided on October 21, 2021. You say that these services 
were necessary and are supported as billed. The Plan says that the payment for codes 83718 and 83721 is 
bundled into the payment for code 80061. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 80076 and 84443.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 80076 and 84443.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 83718 
and 83721. 
 
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 83721 
is a column II code to column I code 80061. This claim has not been billed with an appropriate modifier to 
bypass the edit. In addition, we have confirmed that code 83718 is a column II code to column I code 80061 
with a modifier indicator of 0. The column II code is therefore note 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 the 
services described by procedure code(s) 83718 and 83721. 
 
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.