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

 
We decided that the Plan does not have to pre-approve a new Continuous Positive Airway Pressure (CPAP) 
device replacement and supplies. 
 
You asked the Plan to pre-approve a new CPAP device replacement and supplies. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that if a PAP device is replaced during the 5 year 
reasonable useful lifetime (RUL) because of loss, theft, or irreparable damage due to a specific incident, there 
is no requirement for a new clinical evaluation, sleep test, or trial period. 
 
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 new CPAP device replacement and 
supplies. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this 
case the record indicates that you have obstructive sleep apnea and has been using CPAP. The record does not indicate the age of the current machine. The record does not indicate that an in-person evaluation has occurred 
or that the machine has irreparable damage. 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 a new CPAP device replacement and supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a new Continuous Positive Airway Pressure (CPAP) device 
replacement and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 12, 2021 billed 
with code 81232. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
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. Review of the file shows that this one code was submitted on its own on a separate claim form and 
the other codes were submitted on a different claim form, but the testing was performed at the same time on the 
same specimen. 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 November 12, 2021 billed with code 81232.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are needed for the enrollee to 
return home. The Plan denied your request. The Plan says that the services the enrollee require can safely be 
received at a different setting. 
 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 services. Our reviewer says that 
SNF services are not medically reasonable and necessary. There is no documentation that the patient requires 
skilled nursing services. The patient does require skilled therapy services. There is no documentation that daily 
skilled services are required. There is no documentation that the patient requires services on an inpatient basis, 
only in a skilled nursing facility setting. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4930 billed for date of service December 
29, 2021. 
 
You asked the Plan to pay for procedure code A4930. You say that you disagree with the denial. 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 A4930 has a Status Indicator of N on the Physician Fee Schedule. This means that 
procedure code A4930 is not covered. Based on this information, we decided that Medicare rules for coverage 
of procedure code A4930 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A4930 billed for date of service December 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration as you are unable 
to walk and you live with your sister who can't help you. The Plan denied your request. The Plan says based on 
Medicare guidelines and the services you are requesting do not meet the requirements for approval. 
 
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 you were admitted to an acute hospital on August 11, 2022 with an infected left foot 
with osteomyelitis of big toe and underwent left great toe and second toe amputation on August 14, 2022.  You needed a blood transfusion for anemia. You are stable with a wound VAC in place and the pain is well 
controlled. You are medically stable and no new or acute medical issues are documented. There are no complex 
nursing or rehabilitation needs. While you have a need for physical or occupational therapy, at the current 
functional level you will not make a significant functional progress in an IRF. Your rehabilitation needs can be 
safely provided in an alternate and low intensity setting such as in a skilled nursing facility. 
 
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 the IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
February 7, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test provided for an FDA-
approved indication. The Plan denied your request. The Plan says this test was not billed in accordance with 
Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code.  
Based on this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. 
Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing 
provided on February 7, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FANCC genetic testing rendered on January 25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services were not billed correctly. 
 
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 states that the claim was not billed with the required DEX-Z code, per 
Local Coverage Determination (LCD) L35025; however, this LCD is not valid for the state of Massachusetts 
where the testing is performed. The Plan has not provided any documentation or Medicare rules to support that 
the testing is not covered. Therefore, we decided that the Plan has to pay for the FANCC genetic testing 
rendered on January 25, 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 pre-approve the second opinion (CPT code 99203) to be provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network second opinion. You say that the enrollee has been 
diagnosed with Mesothelioma and has been denied a second opinion. The Plan denied your request. The Plan 
says there is an in-network provider that can perform the services the enrollee needs. 
 
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 the second 
opinion (CPT code 99203) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the dental cleaning (D1110), periodic oral evaluation 
(D0120), and the porcelain/ceramic crown (D2740) provided on October 25, 2021. 
 
You asked the Plan to waive the coinsurance for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the cost 
sharing was applied correctly at a 50% coinsurance.   
 
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 provide the Explanation of Benefits Statement to 
our organization; therefore, we are unable to determine if the coinsurance has been applied correctly to the 
services provided. Therefore, we decided that the Plan has to waive the coinsurance for the dental cleaning 
(D1110), periodic oral evaluation (D0120), and the porcelain/ceramic crown (D2740) provided on October 25, 
2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing due to being a fall risk. The Plan 
denied your request. The Plan says based on Medicare guidelines, the IRF services requested do not meet the 
requirements for approval. 
 
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 patient's nursing medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and 
five days a week, or 15 hours over seven consecutive days. Our physician reviewer also found that while the 
patient has had a decline in function and requires therapy, this does not require the intensity of therapy at the 
level of acute inpatient rehabilitation. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cystourethroscopy a procedure that lets 
a urologist view the inside of the bladder and urethra provided on October 5, 2021. 
 
You asked the Plan to reduce the copayment for the cystourethroscopy. You say that you were bill $400 and 
should have been billed $45 for an office visit and procedure. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 
copayment for surgery services at an outpatient hospital.  
 
You have been asked to pay a $400 copayment for surgery services at an outpatient hospital for the 
cystourethroscopy. The cystourethroscopy falls within the Outpatient Hospital Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the copayment for the cystourethroscopy a procedure that lets a urologist view 
the inside of the bladder and urethra provided on October 5, 2021.
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 member does not meet IRF medical necessity 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 complexity of the patient's nursing medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and 
five days a week, or 15 hours over seven consecutive days. Our physician reviewer also found that while the 
patient has had a decline in function and requires therapy, this does not require the intensity of therapy at the 
level of acute inpatient rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing services (81225, 81226, 81227, 81230, 81231, 81232, 
81291, 81355, 0031U, 0032U, 0033U and 81479) provided on February 22, 2022. 
 
You asked the Plan to pay for genetic testing. You say that these services were medically necessary and were 
ordered by the enrollee's provider. The Plan denied your request. The Plan says that the provider did not write 
an order for this genetic testing and there is no evidence to support that the referring/ordering provider is 
treating this enrollee. 
 
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 records provided include a test requisition form which includes 
the genes at issue in this case, and this form is signed by both the provider and the enrollee. In addition, there 
are medical records in the file which are signed by the requesting provider, including a note which indicates 
that the enrollee met with them to discuss the results. The Plan provided no other argument for the denial of 
these services; therefore, the Plans denial is not substantiated in this case. Therefore, we decided that the Plan 
has to pay for genetic testing services (81225, 81226, 81227, 81230, 81231, 81232, 81291, 81355, 0031U, 
0032U, 0033U and 81479) provided on February 22, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 26, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service March 26, 2022.
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 an Intracept procedure. 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Intracept intraosseous basivertebral nerve ablation at L2-3 
and L4-5, in this case, 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.