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

 
We decided that the Plan has to pay for Decipher Prostate genomic testing (81542) provided on August 5, 
2022. 
 
You asked the Plan to pay for Decipher Prostate genomic testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says that There were no medical notes as to why the 
provider ordered this test, why this number of genes tested, and how the results of the test will impact care 
going forward. Medical notes from the provider are required to see if the test was needed. 
 
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. Medical records are needed to review whether the Plan was correct in denying 
this claim. The Plan has not provided documentation showing that a request was sent to the provider in an 
effort to obtain the missing information. Therefore, we decided that the Plan has to pay for Decipher Prostate 
genomic testing (81542) provided on August 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for a seat lift mechanism 
incorporated into a combination lift-chair mechanism (E0627) provided on March 2, 2022. 
 
You asked the Plan to reimburse you an additional amount for a seat lift mechanism. You say that you disagree 
with the denial. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
You were reimbursed a 20% coinsurance for a seat lift mechanism. This item/service falls within the durable 
medical equipment (DME) and related supplies 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 reimburse 
you an additional amount for a seat lift mechanism incorporated into a combination lift-chair mechanism 
(E0627) provided on March 2, 2022.
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 the enrollee needs continued therapy post 
hospitalization to regain baseline function to ensure safety upon returning home. The Plan denied your request. 
The Plan says the records do not show that it is reasonable to expect the enrollee will be able to safely 
participate in or fully benefit from the intensity of services of an IRF, medically necessary care may be 
provided safely in a different 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. Our 
physician reviewer found 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 health plan. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305, 88312, 88313) provided on May 2, 
2022. 
 
You asked the Plan to pay for the lab services. You say that these services were reported correctly. 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 (88305, 88312, 88313) provided on May 2, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code J3490 billed for date of service September 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code represents charges for medication. The 
Plan denied your request. The Plan says that the initial evaluation code is included when billed the same day as 
a minor procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We looked at the file and the rules. The Plan denied the services as an evaluation and management service is 
included in the payment of a minor procedure. However, we find that CPT code J3490 is not an evaluation and 
management code. The national drug code (NDC) billed on the claim indicates drug Bupivacaine 
Hydrochloride was provided. This is confirmed in the medical records. Based on this information, we decided 
that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the Plan has 
to pay for procedure code J3490 billed for date of service September 8, 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 procedure code A9279 billed for date of service September 
26, 2022. 
 
You asked the Plan to pay for procedure code A9279. You say that this service should be covered. 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 A9279 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A9279 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code A9279 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A9279 billed for date of service September 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycontin 10MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says Oxycontin is a self-administered drug and does not fall under Part B 
coverage. 
 
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 Oxycontin 10MG tablet.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve a PNS. You say that the peripheral nerve stimulator (PNS) is not being 
employed to assess the enrollee's suitability for permanent implants. The Plan denied your request. The Plan 
says that the requested service 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 pre-approve a PNS. Our reviewer says that the 
requested PNS is considered medically reasonable and necessary in this case. Our physician reviewer found the 
provided documentation supports that PNS is coverable for shoulder pain. Therefore, the reviewer found that 
the requested PNS is considered 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 a PNS have been met. Therefore, we decided that the Plan has to pre-approve a 
peripheral nerve stimulator (PNS) (64555).  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission for the enrollee is a medical 
necessity. The Plan denied your request. The Plan says the enrollee is medically stable and no longer requires 
an acute level of care, medically necessary care may be provided safely in a different level of care. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital and receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) lumbar spine 
without contrast, a special picture study of the lower part of the spine without injected dye (72148). 
 
You asked the Plan to pre-approve a lumbar MRI. You say that a lumbar MRI is appropriate for further 
assessment of any progression in nerve compression that could affect treatment. The Plan denied your request. 
The Plan says symptoms must be the same or worse after treatment to support imaging. There was no contact 
with your provider after completing treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 a lumbar MRI. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the is no documentation of six weeks 
of conservative measures for back pain to include physical therapy. 
 
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 lumbar MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) lumbar spine without contrast, a special picture study 
of the lower part of the spine without injected dye (72148).
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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
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 enrollee was admitted for influenza, hyperkalemia, and end stage renal disease. 
The enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs. The 
enrollee does 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. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Implantable (or Insertable Loop) Recorder ((ILR). 
 
You asked the Plan to pre-approve an ILR. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that An ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 ILR. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the patient had no history of atrial fibrillation, 
nor were any significant cardiac arrhythmias. A recent randomized clinical trial found that continuous 
monitoring for atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial 
fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an Implantable (or Insertable Loop) Recorder ((ILR).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Percutaneous laminotomy/laminectomy (0275T). 
 
You asked the Plan to pre-approve the Percutaneous laminotomy/laminectomy. You say that this service is 
medically necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 Percutaneous 
laminotomy/laminectomy. Our reviewer says that the requested service is not considered medically reasonable 
and necessary in this case. Our physician reviewer found this service is considered experimental. 
 
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 Percutaneous laminotomy/laminectomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Percutaneous laminotomy/laminectomy (0275T).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Prolia (CPT code J0897). 
 
You asked the Plan to pre-approve the Prolia. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is 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 the Prolia. Our reviewer says that the 
Medicare-approved major drug compendia there is no documentation that the Prolia at issue in this case meets 
all Medicare criteria for safe and effective for the enrollee. Prolia is indicated for the treatment of 
postmenopausal women with osteoporosis at high risk for fracture; this enrollee has osteoporosis and is 
classified as moderate risk for fracture with a Fracture Risk Assessment Tool (FRAX) 10-year probability for 
major osteoporotic fracture of 11 percent and a FRAX 10-year probability of hip fracture of 2.9 percent. As 
summarized in Up to Date: "A reasonable threshold to define high risk is a 10-year probability of hip fracture 
or combined major osteoporotic fracture of greater than or equal to 3.0 or greater than or equal to 20 percent, 
respectively." 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 Prolia have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Prolia (CPT code J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance, when performed (64454). 
 
You asked the Plan to pre-approve injections. You say that this procedure will address the enrollee's symptoms 
of chronic bilateral knee pain secondary to knee osteoarthritis. The Plan denied your request. The Plan says 
genicular nerve blocks are considered investigational and 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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic bilateral knee pain, right greater than left, due to knee osteoarthritis. 
Genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not 
medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following, 
degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment 
following knee replacement; or as a treatment for individuals who are not candidates for knee replacement 
surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging 
guidance, when performed (64454).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided from December 27, 
2021, to January 1, 2022. 
 
You asked the Plan to pay for SNF care. You say that these services were necessary, were reported correctly 
and are supported in the medical record. The Plan denied your request. The Plan says that they were unable to 
make decision on this case within the required time frame. 
 
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 has provided no clear reason for denial in this case and did 
not include a supporting citation or evidence to support their reasoning. Therefore, we decided that the Plan has 
to pay for skilled nursing facility (SNF) services provided from December 27, 2021, to January 1, 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.