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) for the enrollee. 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is the best option for the enrollee at this time. 
The Plan denied your request. The Plan says that there is no documentation that member has diagnosis of cystic 
fibrosis, bronchiectasis, or a neuromuscular disease. 
 
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 a 
HFCWOD is not medically reasonable and necessary. This patient has COPD, but does not have bronchiectasis, cystic fibrosis, or neuromuscular disease. There is inadequate evidence that HFCWOD is 
effective in the treatment of COPD. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for a HFCWOD. 
 
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) for the enrollee.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for respiratory failure and COVID 
19 pneumonia. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. 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. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
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: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the 
services the enrollee needs can be provided safely in other settings, for example, a skilled nursing facility, or 
home with home health services. 
 
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: 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 stay is medically necessary. 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 the documentation does not support the medical necessity for admission to an IRF. 
While you may benefit from continued physical therapy (PT), and occupational therapy (OT), your 
rehabilitation needs can be safely provided in a lower intensity and alternate setting such as in a skilled nursing 
facility (SNF). 
 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: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88361, 88312, 88305 and 88112) billed 
for date of service December 16, 2021. 
 
You asked the Plan to pay for pathology services. You say that these services were billed appropriately and 
should be paid. The Plan denied your request. The Plan says these services were not billed in accordance with 
Medicare regulations and are missing a necessary modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT codes 88361, 88312, 88305 and 88112 are pathology services which have both professional 
components (PC) and technical components. These services were not billed with modifier 26 to indicate that 
only the professional component payment is requested. This means that payment is requested for both the PC 
and TC of these services. However, these services were provided to an enrollee who was in an outpatient 
hospital setting at the time the sample was collected, which means that the TC component is bundled into the 
facility payment. The TC portion of these services are not separately payable, and therefore these services are 
not supported as billed. Based on this information, we decided that Medicare rules for coverage of pathology 
services have not been met. Therefore, we decided that the Plan does not have to pay for pathology services 
(88361, 88312, 88305 and 88112) billed for date of service December 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the P-C IOL provided on May 19, 2022. 
 
You asked the Plan to pay for the P-C-IOL. You say that you had to have the corrected lenses during your 
cataract surgery instead of the basic lenses and you were told that if you did not have the upgraded lenses that 
you could go blind. The Plan denied your request. The Plan says a presbyopia correcting function of intraocular 
lens is used to correct an astigmatism and is not part of a cataract surgery. Any services done for the correction 
of vision during the surgery are not covered by the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the P-C IOL provided on 
May 19, 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 stay is medically necessary. 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 IRF admission is not medically necessary based lack of medical complexity and 
acute rehabilitation nursing needs. The documentation does not support the medical necessity for admission to 
an IRF. While the enrollee may benefit from continued physical therapy (PT), and occupational therapy (OT), 
the enrollee's rehabilitation needs can be safely provided in a lower intensity and alternate setting such as in a skilled nursing facility (SNF). 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 28, 2022, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81314, 81317, 81321, 81334, 81351, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
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 28, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81314, 81317, 81321, 81334, 81351, 
and 81479.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro custom myoelectric arm brace. 
 
You asked the Plan to pre-approve a MyoPro custom myoelectric arm brace. You say that the requested 
MyoPro custom myoelectric arm brace is medically necessary. The Plan denied your request. The Plan says the 
requested MyoPro custom myoelectric arm brace is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro custom myoelectric arm 
brace. Our reviewer says that the requested MyoPro custom myoelectric arm brace is not medically necessary. 
Our physician reviewer found the requested robotic orthosis is not proven to be more beneficial for treatment of 
the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such 
as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and Botox for spasticity if needed. The requested device is not reasonable 
and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a 
malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe 
for long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. The device is not 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 a MyoPro custom myoelectric arm brace have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a MyoPro custom myoelectric arm brace.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0483) billed for date of service December 13, 2021. 
 
You asked the Plan to pay for drug testing. You say that these services are supported in the medical records. 
The Plan denied your request. The Plan says that the provided documentation does not support that 22 or more 
drug classes were tested in this case. 
 
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 G0483 states that this code is to be used for drug testing of 22 or more drug classes, including 
metabolite(s) if performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records show that drugs 
from more than 22 classes were tested, including alcohol biomarkers, alkaloids, amphetamines, barbiturates, 
benzodiazepines, buprenorphine, cannabinoids (natural), cocaine, fentanyls, gabapentin (non-blood), heroin 
metabolite, ketamine and norketamine, methadone, methylenedioxyamphetamines, opiates, opioids and opiate 
analogs, oxycodone, phencyclidine, pregabalin, propoxyphene, sedative hypnotics (non-benzodiazepines), 
skeletal muscle relaxants, tapentadol and tramadol. Based on this information, we decided that Medicare rules 
for coverage of code G0483 have been met. Therefore, we decided that the Plan has to pay for drug testing 
(G0483) billed for date of service December 13, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) and 
Electrocardiogram, routine ECG (93010) provided on March 31, 2022. 
 
You asked the Plan to pay for the emergency department visit and ECG. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a 
previously paid claim and was correctly denied. 
 
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. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 20, 2022, and June 16, 2022. Comparison of the two claims shows these are 
exact duplicates. There is no evidence presented to support that the billed items/services were provided twice 
on the same date. Based on this information, we decided that the Medicare rules for the emergency department visit, and ECG have not been met. Therefore, we decided that the Plan does not have to pay for the emergency 
department visit (99285) and Electrocardiogram, routine ECG (93010) provided on March 31, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the DecisionDx-Melanoma test provided on April 5, 2022. 
 
You asked the Plan to pay for the testing. You say that fsdfas The Plan denied your request. The Plan says that 
this is not medically necessary. 
 
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 testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that DecisionDx-Melanoma is a validated 31-gene expression profile (GEP) test that was developed to 
identify the risk of recurrence or metastasis including the likelihood of sentinel lymph node positivity for 
patients with stage I, II, or III melanoma and inform patient management decisions. Taken together, the results 
of this analysis and previous clinical validation studies show that the GEP prognostic test is a robust and 
clinically useful tool to implement risk-appropriate healthcare decision-making in CM patients. The requested 
testing in this case is 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 testing have been met. It should be noted that the Local Coverage 
Determination (LCD) referenced by the Plan is not applicable for the jurisdiction in question. Therefore, we 
decided that the Plan has to pay for the DecisionDx-Melanoma test provided on April 5, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 30, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was not 
submitted with the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until April 6, 2022. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the services provided on November 30, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient skilled nursing facility (SNF) care 
provided from March 5, 2022, through April 3, 2022. 
 You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the continued inpatient skilled nursing facility 
care provided was 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 pay for the SNF care. Our reviewer says that the 
inpatient skilled nursing facility care provided was not considered medically reasonable and necessary. Our 
physician reviewer found that as of March 5, 2022, the enrollee did not require any skilled nursing or 
rehabilitation services on a daily basis. She was not expected to make measurable gains within a reasonable and 
predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily 
living. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a 
practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as 
of March 5, 2022. 
 
Additionally, the enrollee did not have any parental medications, complex wound care or nutrition given via a 
feeding tube. The enrollee received skilled care and improved; however, her functional improvement had 
plateaued by March 5, 2022 and she did not require any further inpatient skilled rehabilitation or nursing 
services. The enrollees function was at or near her prior level of function and she could have been discharged 
to a lower level of care for further services. As of March 5, 2022, the enrollee required custodial services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the continued inpatient skilled nursing facility (SNF) care provided from March 5, 2022, 
through April 3, 2022.