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

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on April 13, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claim was billed with a date of service inconsistent with Medicare rules governing 
laboratory services. The records show the specimen was collected on April 6, 2022, not the billed date of 
service April 13, 2022. There is no documentation to support genetic testing on the billed date of service.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the dates on the claim are inconsistent 
with the dates the services appear to have been provided. 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 lab services provided to the enrollee on April 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation services. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation services. You say that this procedure 
is considered medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
requested percutaneous vertebral augmentation is not medically reasonable and necessary 
 
The Plan follows Medicare rules. Medicare rules say that in order for percutaneous vertebral augmentation 
services to be covered, the vertebral fracture must be less than 12 weeks old. 
 
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 percutaneous vertebral augmentation 
services. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our 
physician reviewer found there is no documentation that the vertebral fracture is less than 12 weeks old. 
Therefore, the criteria have not been 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 percutaneous vertebral augmentation services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous vertebral augmentation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography, lower extremity (73701) provided 
on November 20, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee received a bill for $220. You also say that 
you do not understand why this is not covered. The Plan denied your request. The Plan says the claim 
processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that non-contract providers must accept as payment 
in full payment amounts applicable in Original Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the 
computed tomography, lower extremity (73701) provided on November 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kit purchased on June 3, 2022. 
 You asked the Plan to pay for the at-home COVID-19 test kit. You say that you believe that you should receive 
reimbursement for the at-home COVID-19 test kit. The Plan denied your request. The Plan says per Medicare 
guidance, Plans are suggested but not required to provide coverage for COVID-19 at-home tests. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. The rules say 
that although Medicare Advantage plans may cover OTC COVID-19 test kits starting January 15, 2022, they 
are not required to do so. Therefore, we decided that the Plan does not have to pay for the at-home COVID-19 
test kit purchased on June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on April 20, 2022 and 
billed under code 83789-59. 
 
You asked the Plan to pay for code 83789-59. We note the Plan paid for code G0481. You say that this claim 
should be paid. The Plan denied your request. The Plan says code 83789-59 is included in the payment of 
G0481 and cannot be billed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, code 83789-59 cannot be billed 
separately due to its payment inclusion for code G0481. Medicare rules for coverage of code 83789-59 have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee 
on April 20, 2022 and billed under code 83789-59.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on January 21, 2022. 
 
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied 
your request. The Plan says the enrollee had Tempus Gene Panel testing billed with multiple codes. The 
submission of claims using individual gene CPT codes, when either 5-50 or greater than 50 gene panels are 
ordered, is considered incorrect coding. Correct coding requires that when a panel code is ordered, it should be 
billed, rather than the individual gene codes. Additionally, the claim was billed with a date of service 
inconsistent with Medicare rules governing laboratory services. The specimen was collected on January 11, 
2022, rather than the billed date of service January 21, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and date of service information. In this case, this 
claim cannot be paid as billed due to coding errors and discrepancies with the reported dates of service. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services provided to the enrollee on January 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group 
(DRG) 853 provided from September 7, 2021, to September 16, 2021. 
 You asked the Plan to pay for the inpatient hospital services with DRG 853. You say that the medical records 
support the principal diagnosis code A41.9 for sepsis with DRG 853. The Plan denied your request. The Plan 
says the medical records do not support the principal diagnosis code A41.9 for sepsis with DRG 853. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis A41.9. 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 inpatient hospital services with DRG 853. Our reviewer says that 
the medical records do not support the principal diagnosis code A41.9 for sepsis with DRG 853. Our physician 
reviewer found the enrollee is with end-stage renal disease (ESRD) who presented to the hospital with 
worsening right foot wound following missed wound care clinic appointments. He had leukocytosis, elevated 
Cr (near baseline), was agitated, impulsive, and confused with GCS 14, but afebrile with normal vitals on room 
air, no distress, normal bilirubin. He was diagnosed with cellulitis and was started on IV antibiotics. A 
calculated SOFA score of 1 was documented which didn't increase/worsen during the admission. There was 
insufficient evidence documented to meet the Sepsis 3 criteria. Therefore, the medical records do not support 
the billing of sepsis, unspecified organism.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services with diagnosis related group (DRG) 853 provided from September 7, 2021, to 
September 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 19, 2022, to 
April 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claims were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare. 
 
We looked at the file and Medicare rules. The file shows that a valid NOA was not submitted for the billed 
dates of service. The additional documentation submitted does not contain a valid NOA for March 19, 2022. 
Therefore, we decided that the Plan does not have to pay for the home health services rendered from March 19, 
2022, to April 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound rendered on April 13, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until June 11, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the ultrasound rendered on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis 
vaccine (Tdap) (90715), and administration (90471) provided on May 4, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that this was medically necessary to treat the 
enrollee's end stage liver disease. You say that the enrollee cut their hand deeply. You say that their last Tdap 
shot was in 2016. You also say that this claim should be reviewed for payment. The Plan denied your request. 
The Plan says the claim processed correctly. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and 
acellular pertussis vaccine (Tdap) (90715), and administration (90471) provided on May 4, 2022.  
 Benefits for the vaccine services 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81455) provided on April 13, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 find that code 81455 is not supported in the medical record. Specifically, there is no documentation 
describing genetic testing on a sample collected on the date of service at issue. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (81455) provided on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on June 8, 2022. 
 
You asked the Plan to pay for the medical services. You say that your visits with this provider have always 
been paid. The Plan denied your request. The Plan says the provider of these services has opted-out of 
Medicare, so the services cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a 
non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we 
decided that the Plan does not have to pay for medical services provided on June 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device 
(Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says there is insufficient evidence of the efficacy of this 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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan using a Hounsfield 
unit. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this specialized CT scan with Hounsfield units does not have documentation that it is 
any better or more accurate than a standard CT scan, bone scan or DEXA scan to determine bone density or 
mineralization. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found DEXA scan is the gold 
standard test for osteoporosis. CT with Hounsfield unit reporting is not medically needed.  
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) scan using a Hounsfield unit.
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 the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee 
is not yet stable for transfer 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this and do want to go to a nursing home. 
The Plan denied your request. The Plan says this is not medically necessary and the services you need can be 
provided safely in other settings. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee's needs are met in the current 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 all medically necessary care is being provided in the current acute care 
setting. Ongoing care in the acute hospital has been approved by the 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
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 the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of Keytruda is not Food and 
Drug Administration (FDA)-approved for non-small cell lung cancer that has progressed on prior PDL1 
therapy (durvalumab). The use is not supported by the major drug compendia or medical literature. Keytruda is 
therefore not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device. 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested Vertiflex 
Superion interspinous device at L4-5, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device.