Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 enrollees medical conditions appear stable on outpatient medications with no 
issues that appear to require a physicians evaluation three or more times per week. Provided medical records 
do not explain why the intensive inpatient rehabilitation therapy program is necessary and why therapy at a 
lower level of care such as in a skilled nursing facility is not appropriate for her. The enrollee will not be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to her present level of lethargy and limited ability to follow commands as 
documented in therapy notes. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the item is necessary. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 7, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4930 and S1015 billed for date of service 
April 27, 2022. 
 
You asked the Plan to pay for procedure codes A4930 and S1015. You say that the services at issue were billed 
correctly. 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 X on the Physician Fee Schedule. This means that procedure code A4930 is a statutory exclusion. Procedure code S1015 has a Status Indicator of I on the 
Physician Fee Schedule. This means that procedure code S1015 is not valid for Medicare purposes. Based on 
this information, we decided that Medicare rules for coverage of procedure codes A4930 and S1015 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes A4930 and S1015 
billed for date of service April 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman fusion procedure. 
 
You asked the Plan to pre-approve the Minuteman fusion procedure. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Minuteman fusion procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 62-year-old female being treated for spondylolisthesis 
of the lumbar region. In this case, current evidence-based medical guideline and peer-reviewed literature do not 
fully support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack 
of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
medical condition. This enrollee has multiple degrees of spinal stenosis, many not at Food and Drug 
Administration (FDA) indicated levels of moderate spinal stenosis (overall including the planned levels of 
implantation at L4-5 and L5-S1). According to the FDA, The HA Minuteman G3-R MIS Fusion Plate is a posterior, non-pedicle supplemental 
fixation device, intended for use at a single level in the non-cervical spine (T1-S1). The HA Minuteman G3-R 
MIS Fusion Plate is intended for use with bone graft material and is not intended for stand-alone use. The 
documentation does not indicate that this would not be a stand-alone procedure. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the requested Minuteman fusion procedure, 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 the Minuteman fusion procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Minuteman fusion procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external patient auto activated electrocardiographic 
rhythm derived event recording with symptom (93271) and external patient auto activated electrocardiographic 
rhythm derived event recording with symptom (93270) provided from November 3, 2021, to November 17, 
2021. 
 
You asked the Plan to pay for the Zoll cardiac monitoring services. You say that it was not advised that 
authorization was needed for these services. You also say the provider needed to have the enrollee monitored 
for 14 days to properly assess them. The Plan denied your request. The Plan says the medical notes from 
January 4, 2022, are after the loop recorder was done in November 2021, as there is no mention of it in this 
progress note. The Plan also says there were no other medical notes given for this appeal, and without proper 
medical notes, the medical necessity of the appeal in question cannot be determined. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event detection monitoring is reasonable and 
necessary if the enrollee meets any of the indications listed in the Medicare rules section of this letter. 
 
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 Zoll cardiac monitoring services. Our 
reviewer says that these services were not reasonable and necessary. Our physician reviewer found the enrollee 
had a history of palpitations, and this was the stated indication for a mobile cardiac outpatient telemetry 
(MCOT) authorization. As such, guidelines would not support a need for MCOT monitoring in this setting. Our 
reviewer also found that there was insufficient documentation to support the medical necessity for an MCOT 
monitor in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Zoll cardiac monitoring services have not been met. Therefore, we decided 
that the Plan does not have to pay for the external patient auto activated electrocardiographic rhythm derived 
event recording with symptom (93271) and external patient auto activated electrocardiographic rhythm derived 
event recording with symptom (93270) provided from November 3, 2021, to November 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty hospital bed and a heavy-duty trapeze bar 
(0301, E0303). 
 
You asked the Plan to pre-approve a heavy-duty hospital bed and a heavy-duty trapeze bar. You say that the 
requested bed is medically necessary due to spinal stenosis, lumbar region without neurogenic claudication. 
The Plan denied your request. The Plan says the requested bed does not meet coverage criteria. 
 
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 heavy-duty hospital bed and a heavy-
duty trapeze bar. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found provided records do not document that you have a 
medical condition which requires positioning of the body in ways not feasible with an ordinary bed or you 
require positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain. You do not 
require the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, 
chronic pulmonary disease, or problems with aspiration, or he requires traction equipment, which can only be 
attached to a hospital bed. In addition, the trapeze does not meet criteria for coverage, as provided records do 
not document the need to sit up because of a respiratory condition, to change body position for other medical 
reasons, or to get in or out of bed. 
 
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 heavy-duty hospital bed and a heavy-duty trapeze bar have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a heavy-duty hospital bed and a heavy-duty 
trapeze bar (0301, E0303).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service March 8, 
2022. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for laboratory services have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We looked at the file and Medicare rules. The case record indicates that the specimen was not collected on the 
billed date of service. In this case, there are no apparent grounds for an exception to the rules. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service March 8, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on November 19, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that the service should be covered. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 15, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray 
(71045) provided on November 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport rendered on November 24, 2021. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with a complete or 
valid diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pay for the ambulance transport rendered on November 
24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5259) provided on March 1, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the documentation provided does not support the 
billed item in this case. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. All services that do not have an appropriate proof of delivery will be 
denied.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this item have not been met. Specifically, the record does not include a physician/qualified 
healthcare professionals order or documentation indicating the hearing aid at issue in this case was dispensed 
on the billed date of service. Therefore, we decided that the Plan does not have to pay for the hearing aid 
(V5259) provided on March 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 2, 2021, 
to December 16, 2021. 
 
You asked the Plan to pay for the home health services. You say that the claims should be paid. The Plan 
denied your request. The Plan says no exception request was submitted to waive the 5-day requirement for 
filing the RAP claim due to a circumstance beyond the provider's control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, September 2, 2021, October 2, 2021, November 1, 2021, and December 1, 2021. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from September 2, 2021, to December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, 51 or greater 
genes (81455) provided March 1, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the documentation included with your appeal 
provides all of the applicable information needed to adequately consider your appeal. The Plan denied your 
request. The Plan says does not meet Medicare NCD/LCD criteria. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes 
(eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, 
KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), 
interrogation for sequence variants and copy number variants or rearrangements, if performed. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the specimen was collected 
February 16, 2022 rather than the billed date of service March 1, 2022. Genetic testing procedures submitted 
with code 81455 are also unlikely to impact therapeutic decision-making in the clinical management of the 
patient and will be denied automatically as not medically necessary. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the targeted genomic sequence analysis panel, 51 or greater genes (81455) provided 
March 1, 2022.
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 81194, 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81309, 81317 and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare rules. 
 
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 81194, 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 
81309, 81317 and 81401.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on February 24, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that you disagree with the Plan's denial The Plan 
denied your request. The Plan says that the claim does not meet Medicare NCD/LCD criteria. 
 
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. Medicare rules also say that Medicare nationally covers FDA-approved NGS testing, such as the 
F1CDx panel, when provided for an FDA-approved indication. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan use Local Coverage Determination (LCD) 
L35025 and Local Coverage Article (LCA) A56853 to support their denial. However, LCD L35025 and LCA 
A56853 are not valid for the provider's head quarter billing state of Pennsylvania. This means we are unable to 
use LCD L35025 and LCA A56853 to substantiate our decision. This testing was provided to a patient with a 
solid tumor. The FDA approval notice indicates that this panel is approved for solid tumors. No other valid denial 
rationale was presented by the Plan. Therefore, we decided that the Plan has to pay for the FoundationOne CDx 
(F1CDx) testing provided on February 24, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on 
February 1, 2022. 
 
You asked the Plan to pay for the surgical pathology services. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, this code was billed with 
place of service 81 (independent laboratory). The documentation shows that the enrollee was an outpatient for 
this date of service. In addition, another provider rendered the same service code on the same date of service 
with place of service 22 (outpatient hospital).  
 Based on this information, we decided that Medicare rules for coverage of the surgical pathology services have 
not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology services 
coded 88305 provided on February 1, 2022.