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

 
We decided that the Plan does not have to pay for the GeneSight psychotropic assay (81479) provided 
November 15, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that please accept this appeal letter and the attached 
statement of medical necessity, and test request for as your request for a retroactive authorization request. The 
Plan denied your request. The Plan says review of the documentation does not support that the medical 
necessity criterion have been met. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, there is no documentation in the clinical record that the provider has already 
considered any non-genetic factors to make a preliminary drug selection. The LCD also lists special 
documentation requirements for pharmacogenetic testing to be covered.  There is no documentation that the 
clinician has made an initial personalized decision for the patient based on the criteria listed in the LCD. The 
review has determined that the items/services at issue in this case are 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the GeneSight psychotropic assay (81479) provided November 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of Crohn's 
disease. The Food and Drug Administration (FDA) has stated that the requested drug is indicated for the 
enrollee's condition; however, the record provided is insufficient to establish the medical necessity of the 
requested drug at this time. The services are not safe and effective or reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Stelara.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that these lab services were medically necessary and 
should be covered. 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, for 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 provided on November 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S5000 billed for date of service May 2, 2022. 
 
You asked the Plan to pay for procedure code S5000. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S5000 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S5000 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S5000 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S5000 billed for date of service May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
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 is being offered radiation 
therapy for a skin cancer of the scalp with positive margins after resection. The current National 
Comprehensive Cancer Network (NCCN) guidelines do not address the use of proton therapy for this 
diagnosis. The use of proton beam therapy is not the standard of care and is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the external mobile cardiovascular telemetry with electrocardiographic 
recording services identified with code 93229 provided on October 3, 2022. 
 
You asked the Plan to pay for the external mobile cardiovascular telemetry with electrocardiographic recording 
services. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says that the 
services rendered are not covered. 
 
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. Review of the file shows that the Plan states that the diagnosis code billed is not 
on the list of applicable diagnosis codes for the code rendered. The Plan also states that a medical necessity 
review was not completed as the denial was not for medical necessity. However, the Plan used Plan criteria to 
support this denial without the use of any actual Medicare rules or criteria. The Plan criteria cited even states 
"The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of 
a code in this guideline does not imply that the service described by the code is a covered or non-covered 
health service". This means the criteria does not state that any diagnosis not listed is not covered for the 
services rendered. No other denial rationale was provided. The Plan did not substantiate their denial. Therefore, 
we decided that the Plan has to pay for the external mobile cardiovascular telemetry with electrocardiographic 
recording services identified with code 93229 provided on October 3, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered upper extremity orthosis (L8702). 
 
You asked the Plan to pre-approve the MyoPro powered upper extremity orthosis. You say that this device is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 MyoPro powered upper extremity 
orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this 
case. Our physician reviewer found randomized studies have failed to show consistent benefit from the device 
for individuals such as the enrollee. 
 
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 MyoPro powered upper extremity orthosis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a MyoPro powered upper extremity orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided superficial radiation therapy. 
 
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 use of ultrasound on a daily basis is 
not supported by consensus guidelines and is not the standard of care. The requested services are 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 image-guided superficial radiation therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 6, 2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. 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 genetic testing 
provided on December 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says LTACH care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for admission to 
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The review has 
determined that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after April 
2, 2023. 
 You asked the Plan to pre-approve SNF care after April 2, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF 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 SNF care after April 2, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after April 2, 2023, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care after April 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service July 20, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service July 20, 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 want physical therapy. The Plan denied your 
request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have complex nursing or rehabilitation needs. While the medical 
record supports 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 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you need a new set of dentures as the 
previous set from 2019 never fit your mouth, and the dentist refused to correct the dentures. The dentures fall 
out of your mouth and will not stay in without an excessive amount of denture glue. You also express that it is 
very difficult for you to eat with these dentures, and you need a new set. 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 on date of service September 16, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reverse shoulder arthroplasty. 
 
You asked the Plan to pre-approve reverse shoulder arthroplasty. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan 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 reverse shoulder arthroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no compelling rationale is presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the request for is 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 reverse shoulder arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve reverse shoulder arthroplasty.
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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of IRF care is correct. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that the enrollee will be able to fully participate in 
- and benefit from - the intensive rehabilitation care 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve Prednisone. You say that this drug is medically necessary to treat the 
patient's polymyalgia rheumatica. The Plan denied your request. The Plan says this drug is not covered under 
the patient's medical benefits.  
 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 Prednisone.  
 
Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.