Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF services to facilitate 
increased independence and return home with an improved quality of life. You also say the required services 
for the enrollee cannot be safely met with home health services or a skilled nursing facility (SNF) at this time. 
The Plan denied your request. The Plan says the requested IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 
the 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
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 wound care supplies provided on October 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for wound care supplies. You say that these items do not require authorization. The 
Plan denied your request. The Plan says items and services provided out-of-network require authorization. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound care supplies provided on October 7, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 13, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are appealing for the wrongful 
denial for intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. 
The Plan denied your request. The Plan says medical studies haven't proven this service/item is helpful for the 
treatment of your health problem. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found one double-blind randomized study has shown that improvement with the Intracept 
procedure was not clinically significant when compared with a sham procedure. Additional studies suggest that the Intracept procedure may be more effective for low back pain than conservative treatment. Limitations of the 
published medical literature include a limited number of studies, industry funding of the studies, and a high risk 
of bias from lack of controls. Additional study is needed to validate any benefit of the procedure, and to 
compare it to other interventions. Current medical literature indicates that the Intracept procedure is 
investigational 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on December 21, 2021. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or 
more pathogens are non-covered.  
 
We looked at the file and Medicare rules. The panel in this case tested 6 or more pathogens, which is not 
covered per L37713. Based on this information, we decided that Medicare rules for coverage of the panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab panel provided on December 
21, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (code 81455) provided on August 18, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the genetic testing was medically necessary. The 
Plan denied your request. The Plan says that the genetic testing is experimental. 
 
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 genetic testing. Our reviewer says that the 
requested genetic testing is considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is a 68-year-old female with a history of moderately to poorly differentiated 
adenocarcinoma. The review indicates that genomic profiles of circulating cell-free tumor DNA (ctDNA) have 
been shown to closely match those of the corresponding tumors, with important implications for both 
molecular pathology and clinical oncology. Analyses of circulating nucleic acids, commonly referred to as 
'liquid biopsies', can be used to monitor response to treatment, assess the emergence of drug resistance, and 
quantify minimal residual disease. In addition to blood, several other body fluids, such as urine, saliva, pleural 
effusions, and cerebrospinal fluid, can contain tumor-derived genetic information. The molecular profiles 
gathered from ctDNA can be further complemented with those obtained through analysis of circulating tumor 
cells (CTCs), as well as ribonucleic acid (RNA), proteins, and lipids contained within vesicles, such as 
exosomes. In this case, there is no tissue for analysis. The genetic testing at issue 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 genetic testing have been met. Therefore, we decided that the Plan has to pay 
for genetic testing (code 81455) provided on August 18, 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 inpatient psychiatric care from April 11, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from April 11, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from April 
11, 2023, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of April 11, 2023, forward. Our physician reviewer found you did not 
require inpatient mental health treatment beyond April 11, 2023, as you were not a danger to yourself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from April 11, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from April 11, 
2023, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on October 25, 
2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract provides coverage for hearing aids 
only when purchased through the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids purchased on October 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet the criteria for an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 
the 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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel provided on 
July 7, 2022, billed with codes 87798, 87150, 87481, 87801, 87640, 87500, 87653 and 87651. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary and is 
supported in the medical records. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR panel have not been met. Specifically, the records show that this was a single panel 
which was unbundled and reported with multiple codes. Therefore, we decided that the Plan does not have to 
pay for the urine PCR (polymerase chain reaction) panel provided on July 7, 2022, billed with codes 87798, 
87150, 87481, 87801, 87640, 87500, 87653 and 87651.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the opioid treatment program (OTP) services provided on December 
12, 2022. 
 
You asked the Plan to pay for the OTP services. You say that the facility is correctly certified to provide and be 
reimbursed for these services. The Plan denied your request. The Plan says that this was billed by an individual 
physician which is not allowed. 
 
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 rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for the opioid treatment 
program (OTP) services provided on December 12, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tracheostomy (31600) provided on June 8, 2022. 
 
You asked the Plan to pay for the tracheostomy (31600). The Plan denied your request. The Plan says 
procedure code 31600 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 31600 is tracheostomy, planned (separate procedure). 
  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 tracheostomy (31600). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report describes a #8 tracheostomy tube being removed, then a #10 tracheostomy tube was inserted. 
The procedure describes a replacement was performed. Therefore, this procedure code 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 tracheostomy (31600) have not been met. Therefore, we decided that the 
Plan does not have to pay for the tracheostomy (31600) provided on June 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 5, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xF liquid biopsy testing (81455) provided on 
November 3, 2022. 
 
You asked the Plan to pay for Tempus xF testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test is not approved by the 
FDA for the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for Tempus xF testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records provided in this case document the clinician's opinion about the test as, "we 
discussed the option of broad molecular profiling through a platform such as Foundation One or Tempus. 
Occasionally this will reveal certain mutations that are more suggestive of a particular primary and can also 
occasionally inform treatment decisions, but I also told him that the results are not always informative." The 
records provided in this case do not clearly document that the enrollee has not previously been provided this 
same test for this same cancer genetic content and that this test has received FDA approval or clearance as a 
companion in vitro diagnostic and there is an FDA-approved or -cleared indication for use of this test in this 
enrollees cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tempus xF testing have not been met. Therefore, we decided that the Plan does 
not have to pay for Tempus xF liquid biopsy testing (81455) provided on November 3, 2022.