Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says your 
records do not show that you need continued treatments and care that can only be given in a hospital setting. 
 
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 transfer to the LTACH is not medically necessary as you are not yet stable and as it 
would not be clinically advantageous at this time. Completion of treatment at the current facility is 
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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis panel billed with multiple codes including 
87481 and 87798 for date of service April 27, 2022. 
 
You asked the Plan to pay for the urinalysis panel. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says these services were not billed in accordance 
with Medicare billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 infectious disease pathogen identification testing have not been met. Specifically, the records show 
that a single panel was ordered and performed, but this service was billed by reporting individual components. 
Therefore, we decided that the Plan does not have to pay for the urinalysis panel billed with multiple codes 
including 87481 and 87798 for date of service April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 6, 2022. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
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 
May 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due 
to insufficient evidence of efficacy. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the lumbar magnetic resonance imaging (MRI) did not demonstrate Modic changes at all 
the requested surgery levels. In this case, there were/are multiple plausible pathologic sources of significant 
pain generation. The non-radiating midline back pain, the noted pain-aggravating factors (walking and standing 
straight), pain-relieving factors (by leaning over on something), and limited lumbar exam were/are all non-
specific to any pathologic entities. Overall, 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. The 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 L3, L4, 
and L5 vertebral bodies, 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the prescribed dose for this enrollee is 
relatively high but is in accordance with the doses recommended by National Comprehensive Cancer Network 
(NCCN) guidelines. The IMRT plan results in marked reduction in bowel exposure, such that it is plausible that 
IMRT could be of benefit in this enrollee in lowering the toxicity risk to the bowel. The reduction in the bowel 
and rectum are clinically meaningful as high dose exposure can result in bowel toxicity and fracture risks 
which has a risk of morbidity and mortality. IMRT is within the standard of care and medically necessary at 
this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve intensity-modulated radiation therapy (IMRT).  
 
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 an inpatient stay. 
 
You asked the Plan to pre-approve an inpatient stay. You say that the enrollee has osteoarthritis, has tried other 
treatments for longer than six months, and their pain interferes with daily activities. The Plan denied your 
request. The Plan says the requested hospital stay is not covered because it is associated with a procedure that 
is not covered. 
 
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 an inpatient stay. Our reviewer says that 
the documentation does not support that the criteria for inpatient coverage are met in this case. Our physician 
reviewer found the enrollee has been approved for a right reverse total shoulder arthroplasty. This is a request 
for inpatient services related to this elective, non-emergent procedure. Our reviewer also found that the 
provided documentation does not reveal the enrollee with any unstable condition, with high risk factors to 
suggest they would require hospital services that would likely cross 2 midnights for this typically ambulatory 
procedure. 
 
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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an inpatient stay.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter placement of intravascular stents. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this does not meet the requirements and cannot be approved. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this case, the record indicates that the enrollee has a 4.9 mm anterior communicating 
aneurysm. UptoDate states that small (less than 7 mm) aneurysms in patients without previous subarachnoid 
hemorrhage (SAH) should be treated with observation rather than intervention. The elements of the coverage 
criteria are not satisfied. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter placement of intravascular stents.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve the Myriad MyRisk test. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no recurrence of cancer or a new diagnosis of inheritable cancer type. 
 
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 the testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that per the National Comprehensive Cancer Network (NCCN) guidelines, the criteria is met based on a 
1st degree relative (sister) with colorectal cancer before the age of 50. Given breast cancer in the mother, and a 
leukemia in a paternal aunt, other genetic mutations are possible. The enrollee also has a personal history of 
cancer. Panel genetic testing was reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have been met. Therefore, we decided that the Plan has to pre-
approve the Myriad MyRisk test.  
 
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 laboratory testing provided on August 11, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that this claim should be paid in full. The Plan 
denied your request. The Plan says additional information was needed to determine how the enrollee came to 
the servicing provider or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the laboratory testing have been met. 
The Plan provided documentation showing that multiple requests for additional information were sent to the 
provider. This information was not returned. Without medical records we are unable to review the medical 
necessity of the laboratory services at issue. Therefore, we decided that the Plan does not have to pay for the 
laboratory testing provided on August 11, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost sharing for the botox injection. We decided that the Plan does 
not have to waive the cost sharing for the botox injection and the lab services.  
 
 You asked the Plan to reduce the cost sharing for the botox injection provided by an in-network provider on 
September 8, 2022, and lab services provided by an in-network provider on October 18, 2022. You say that you 
do not agree with the cost sharing applied to these services. The Plan says that this cost sharing was charged 
correctly. 
 
We decided that the Plan has to reduce the cost sharing for the botox injection.  
 
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 says that you must pay a 20% 
coinsurance for in-network Medicare Part B covered drugs.  
 
The Plan says you must pay a $400 copayment for Medicare Part B covered drugs. Based on the Plan contract, 
however, you cannot be asked to pay more than a 20% coinsurance for Medicare Part B covered drugs. In this 
case, 20% of the $1871.28 allowed amount for the botox injection is $374.26. Therefore, we decided that the 
Plan has to reduce the copayment for the botox injection. 
 
We also decided that the Plan does not have to waive the cost sharing for the botox injection and the lab 
services. 
 
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 $40 
copayment for in-network lab services provided at an outpatient hospital facility, and a 20% coinsurance for in-
network Medicare Part B covered drugs. 
 
You have been asked to pay a $34.52 copayment for the lab services because the allowed amount for these 
services is less than the $40 copayment. These items/services fall within the outpatient diagnostic tests and 
therapeutic services and supplies benefit category. You are also responsible for a cost share of $374.26 for the 
botox injection ($1871.28 allowed amount x .20 = $374.26). This item/service falls within the Medicare Part B 
prescription drugs benefit category. 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 waive the cost sharing for the botox 
injection and the lab services. 
 
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 procedure code(s) 88341, 88342 and 88360 billed for date of 
service April 7, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342 and 88360. You say that these services were 
necessary and were reported correctly. The Plan denied your request. The Plan says this code is included in the 
facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342 and 
88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342 and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342 and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342 and 88360 billed for date of service April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted dialysis procedure coded 90999 provided on 
August 30, 2022. 
 
You asked the Plan to pay for the unlisted dialysis procedure. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding 
regulations. 
 
The Plan must follow Medicare rules. Medicare rules state that ESRD services required specific items to be 
billed on the claim. Review of the file shows that the claim was missing D5 value code. Therefore, we decided 
that the Plan does not have to pay for the unlisted dialysis procedure coded 90999 provided on August 30, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laminectomy (63047, 63408). 
 
You asked the Plan to pre-approve spinal surgery. You say that the enrollee was already approved for the 
services before switching insurance carriers. The Plan denied your request. The Plan says there is insufficient 
documentation to show that the criteria for medical necessity have been met for the requested procedure. 
 
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 spinal surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding significant neurological compromise on the 
examinations. The exam reveals intact strength and reflexes. Straight leg raise is negative bilaterally. The noted 
magnetic resonance imaging (MRI) did not corroborate any significant spinal stenosis or nerve encroachment 
at the requested surgical levels. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested laminectomy at L3-4 levels, 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 spinal surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a laminectomy (63047, 63408).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on September 
29, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON evaluation and management services. You say that the documentation 
provided supports the services in dispute. The Plan denied your request. The Plan says this is not a network 
provider and the services in dispute were not urgent, emergent, or pre-approved. 
 
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 evaluation and management services provided on 
September 29, 2022, by an out-of-network (OON) provider.