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

 
We decided that the Plan has to pay for unlisted molecular pathology (81479) provided on April 13, 2022. 
 
You asked the Plan to pay for unlisted molecular pathology. You say that you want the Plan to pay for the 
service at issue. The Plan denied your request. The Plan says that the claim was billed with a date of service 
inconsistent with Medicare rules governing laboratory services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide evidence to support that the sample at issue was not 
taken during an outpatient encounter. As such, the denial based on the date of service being incorrect is not 
supported. Based on the rules cited in the Medicare rules section, the DOS for this testing can be reported as 
the date that the services were performed if the sample was taken during an outpatient hospital encounter. The 
Plan has not submitted evidence showing the patient status when the sample was taken. As such, we find that 
the denial based on the DOS is not supported. Therefore, we decided that the Plan has to pay for unlisted 
molecular pathology (81479) provided on April 13, 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: 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 in order for the enrollee to be able to return home at 
their maximum level of functioning, the enrollee's medical management and rehabilitation needs require an 
inpatient rehabilitation stay and close physician supervision. The Plan denied your request. The Plan says the 
stay is not medically necessary based on IRF criteria. 
 
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 there is not a reasonable expectation that this enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like to continue inpatient physical and 
occupational therapy to help increase mobility and strength. The Plan denied your request. The Plan says your 
request for continued admission in SNF does not meet the requirements for approval. 
 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. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that as of October 15, 2022, you did not require skilled services on an inpatient basis, 
at a SNF level of care. You are at or near your prior level of function and could be discharged to a lower level 
of care for further 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service November 
30, 2021. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99291 is bundled into payment for code 31500. 
 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 99291 
is a column II code to column I code 31500. 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 99291 billed for date of service November 30, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee arthroscopy (G0289) provided on May 20, 2022. 
 
You asked the Plan to pay for the knee arthroscopy (G0289). You say that the operative report should be 
reviewed, and the claim reconsidered for payment. The Plan denied your request. The Plan says procedure code 
G0289 is not supported by the medical records submitted. 
 
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 G0289 is arthroscopy, knee, surgical, for removal of 
loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other 
surgical knee arthroscopy in a different compartment of the same knee. 
 
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 knee arthroscopy (G0289). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the operative report does not include enough documentation to verify the code criteria; therefore, this procedure 
cannot be verified.  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 knee arthroscopy (G0289) have not been met. Therefore, we decided that 
the Plan does not have to pay for the knee arthroscopy (G0289) provided on May 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 the enrollee has had an amputation and now needs 
therapy to help with getting stronger. The Plan denied your request. The Plan says the stay is not medically 
necessary based on IRF criteria. 
 
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 there is not a reasonable expectation that this enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve a BRCA 1 and 2 full sequencing for the enrollee. 
 
You asked the Plan to pre-approve the sequencing. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the records do not show signs or symptoms of hereditary cancers. 
 
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 pre-approve the sequencing. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that per the National Comprehensive Care Network (NCCN) Guidelines Version 1.2023 Gene Summary: 
Risks and Management patients with a personal family history of melanoma and metastatic prostate cancer are 
at risk for a family cancer syndrome, especially BRCA2. BRCA testing is 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 the sequencing have been met. Therefore, we decided that the Plan has to pre-
approve a BRCA 1 and 2 full sequencing for the enrollee.  
 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: Partially Favorable

 
We decided that the Plan has to adjust the coinsurance for the chiropractic manipulative treatment (98942, 
98943) provided from January 31, 2022, through April 13, 2022. We also decided that the Plan does not have 
to issue reimbursement for the office visits (99212, 99214), manual therapy (97140), self-care management 
training (97535), hot or cold packs therapy (97010), and the electrical stimulation (97032) provided from 
January 31, 2022, through April 13, 2022.  
 You asked the Plan to issue reimbursement for these services. Additionally, you asked the Plan to adjust the 
coinsurance for the chiropractic manipulative treatment provided. You say that you are requesting a 
reconsideration of the Plans denial for payment. The Plan says that these services are not covered under your 
contractual policy or by Medicare. Additionally, the Plan says that the coinsurance has been applied correctly 
to the chiropractic manipulative treatment services provided.  
 
We decided that the Plan has to adjust the coinsurance for the chiropractic manipulative treatment 
(98942, 98943) provided from January 31, 2022, through April 13, 2022.  The Plan contract says that 
enrollees must pay a 50% coinsurance for Medicare-covered chiropractic services rendered by an out-of-
network provider. The provider in this case is an out-of-network provider. The Plans allowed amounts for 
these services were incorrectly applied as your coinsurance liability. Therefore, we decided that the Plan has to 
adjust the coinsurance applied to reflect 50% of the billed charges for the chiropractic manipulative treatment 
(98942, 98943) provided from January 31, 2022, through April 13, 2022.   
 
We also decided that the Plan does not have to issue reimbursement for the office visits (99212, 99214), 
manual therapy (97140), self-care management training (97535), hot or cold packs therapy (97010), and 
the electrical stimulation (97032) provided from January 31, 2022, through April 13, 2022. The Plan 
contract says that the only covered chiropractic service is manual manipulation of the spine to correct a 
subluxation. The services at issue are not covered by the Plan or by Medicare. Therefore, we decided that the 
Plan does have to issue reimbursement for the office visits (99212, 99214), manual therapy (97140), self-care 
management training (97535), hot or cold packs therapy (97010), and the electrical stimulation (97032) 
provided from January 31, 2022, through April 13, 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 incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee has a script for pads which 
are needed for her mattress. The Plan denied your request. The Plan says the requested services are not a 
covered benefit under the enrollees Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 4 standard, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0884) and accessories 
(E2300, E2363, K0108). 
 
You asked the Plan to pre-approve a group 4, power wheelchair and accessories. You say that you have a group 
3 PWC, and you need the group 4 PWC to be more independent in the home. You are unable to safely 
ambulate even with an assistive device. Only the group 4 PWC can provide the improved suspension, 
battery/motor life, wider base support for stability and safety that a group 3 PWC cannot provide. The Plan 
denied your request. The Plan says the requested group 4 power wheelchair and requested accessories are not a 
Medicare covered benefit. 
 The Plan follows Medicare rules. Medicare rules say that the group 4 power wheelchairs have added 
capabilities that are not needed for use in the home. 
 
The records show you currently have a group 3 power wheelchair. Medicare rules say that the group 4 power 
wheelchairs have added capabilities that are not needed for use in the home. Therefore, if these wheelchairs are 
provided, they will be denied as not reasonable and necessary. This means that Medicare rules for coverage of 
a PWC have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and 
including 300 pounds (K0884) and accessories (E2300, E2363, K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bariatric surgery. 
 
You asked the Plan to pre-approve bariatric surgery. You say that that you have a BMI of 36.8 and high 
cholesterol and your back hurts so much that you are in excruciating pain. You say that you are now 201 lbs. 
and 5'1" tall. You say that you are dedicated to do whatever it takes as you have tried & failed at diet exercise, 
keto diets, low carb, vegan, calorie dense, Mediterranean and & dash diets & lypo suction and you also have 
lymphedema in your right leg that happened after weight gain. The Plan denied your request. The Plan says 
Medicare criteria for coverage of bariatric surgery limit coverage to those patients whose BMI is 40 or greater. 
Alternatively, for patients with a BMI of more than 35 but less than 40, typically must have one of the 
following co-morbid health conditions such as Hypertension, type 2 DM, or sleep apnea. 
 
The Plan follows Medicare rules. 
 
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 bariatric surgery. Our reviewer says 
that bariatric surgery is not medically necessary. Our physician reviewer found that although you have a BMI 
that is greater than 35 kg/m2 with at least one obesity condition, hypersensitivity lung disease (HLD), your 
primary care provider (PCP) has requested psychiatric evaluation given your significant past psychiatric and 
drug use disorder history. You have attempted diets in the past but have not documented physician supervised 
efforts. Given the PCP's clinical concerns, psychiatric/psychological evaluation should be considered before 
medical necessity can be determined.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bariatric surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bariatric surgery.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis. 
 
You asked the Plan to pre-approve Hymovis. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Hymovis. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick urine collection system. 
 
You asked the Plan to pre-approve a Purewick urine collection system. You say that the requested Purewick 
urine collection system is medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for the requested Purewick urine collection system. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Purewick urine collection system. Our 
physician reviewer found the enrollee does not meet criteria for the requested Purewick urine collection 
system.  The records do not show that the requested Purewick urine collection system is being requested as an 
alternative to an indwelling catheter. 
 
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 Purewick urine collection system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Purewick urine collection system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 2, 2020. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 December 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (81455) provided April 
11, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this letter and the attached documents 
support the medical necessity of the tests requested. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
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 find that CPT code 81455 is not supported in the medical record. Specifically, the claim was 
billed with a date of service inconsistent with Medicare rules governing laboratory services. A specimen was 
collected on November 29, 2018, rather than the billed date of service April 11, 2022. Based on this 
information, we decided that Medicare rules for coverage of the laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis (81455) 
provided April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs this procedure 
because of her diagnosis. The Plan denied your request. The Plan says the enrollee has not had syncope. 
 
The Plan follows Medicare rules. Medicare rules say that electrocardiographic services are only covered under 
certain medical 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 services. Our physician 
reviewer found that while the enrollee has a history of atrial fibrillation, there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent indication for an ILR. 
There is insufficient documentation to support the medical necessity for insertion of an ILR in this enrollees 
clinical management. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an implantable loop recorder.