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

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis, 51 or greater genes 
(81455) provided January 25, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that FoundationOneHeme was ordered by the 
treating physician because the test results were needed to help determine the course of treatment for this 
enrollee. Please find supporting documentation and evidence to support medical necessity. The Plan denied your request. The Plan says services do not meet coverage requirements. There is no evidence to support the 
referring/ordering provider is/was treating the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Outreach was made to the referring/ordering provider listed on the 
claim by the Plan. The provider advised that they did not order the genetic testing for the enrollee. There is no 
evidence to support that this provider was treating the patient. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for targeted genomic sequence analysis, 51 or greater genes (81455) provided January 25, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (CPT code J0897). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the drug is not being prescribed for a medically-accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found Prolia is not FDA-approved for hypercalcemia due to secondary/tertiary hyperparathyroidism. The use of 
Prolia for treatment of hypercalcemia due to secondary/tertiary hyperparathyroidism is not supported by one of 
the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services 
(CMS)-approved medical journal. 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 medication have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Prolia (CPT code J0897).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for outpatient therapy services (97110, 97112, 97116, 97530 and 97535) 
provided from November 1, 2021, to November 12, 2021. 
 
You asked the Plan to pay for outpatient therapy services. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says that these services were provided in a home 
health or hospice setting and should be billed with a different code. 
 
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 the outpatient therapy services are supported in the medical record with the codes billed. 
Specifically, these services were provided in the enrollee's home, which was an assisted living facility rather 
than a home health or hospice setting. These services were not rendered or billed under a home health or 
hospice plan of care. Based on this information, we decided that Medicare rules for coverage of outpatient 
therapy services have been met. Therefore, we decided that the Plan has to pay for outpatient therapy services 
(97110, 97112, 97116, 97530 and 97535) provided from November 1, 2021, to November 12, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that you filed a claim for reimbursement but the 
payment was sent to the provider instead. The Plan denied your request. The Plan says you have not provided 
proof of payment for this claim.  The Plan says that it called you to request proof of payment, but were 
unsuccessful.  The Plan has stated that once it receives proof of payment, the claim will reprocess and pay. 
 
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 lab services provided on March 18, 
2022. have been met. Specifically, you have not provided proof of payment to the Plan.  The Plan has indicated that once it receives proof of payment, this claim will process to pay you. Therefore, we decided that the Plan 
does not have to pay for lab services provided on March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 18, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81306, 81355, 81335, 82328, 81291, 81407, 81238, 81479, 81406, 
0331U, 0332U and 0334U. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
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 
April 18, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81306, 81355, 81335, 82328, 81291, 
81407, 81238, 81479, 81406, 0331U, 0332U and 0334U.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81529) provided on June 1, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 81529 is not supported in the medical record. Specifically, the date the specimen was 
collected (May 16, 2022) does not match the date of service billed. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (81529) provided on June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on December 17, 2021. 
 
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 our records show the enrollee was an outpatient on this date of service and that the 
facility rendered procedure 88305 on the date of service December 17, 2021. The records show another 
provider rendered service code 88305 on the same date of service and place of service 22 for Outpatient 
Hospital. Medicare guidelines show this code has a Physician Fee Schedule PCTC indicator of 1. Based on the 
location of the patient and the service provided, payment of this code is included in the facility claim.  
 
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 provider has billed a service 
included in the facility claim which is not separately payment. 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 December 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI, brain (including brain stem); without contrast 
material, followed by contrast material(s) and further sequences (CPT code 70553) to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network service. You say that the service is necessary. The Plan 
denied your request. The Plan says there is an in-network provider that can perform the services the enrollee 
needs. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve MRI, brain (including brain stem); without contrast material, followed by contrast material(s) and further 
sequences (CPT code 70553) to be provided by an out-of-network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not been 
met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Retacrit or Epogen before they will approve the requested drug. The enrollee has 
not tried and failed the required drugs. There is no documentation that the Plans required drugs likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Aranesp (J0881).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says 
admission to the LTACH was denied as not meeting criteria, is not medically necessary, and the required care 
can be provided at, for example the acute care 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 you were admitted to the acute care hospital with acute respiratory failure related to 
COVID-19 and hyponatremia. You were treated with antibiotics, high flow oxygen support, BiPAP, Precedex, 
and Voriconazole for a fungal infection. You refused intubation.  Recent notes describe you as still dependent 
on high flow oxygen and BiPAP without significantly improved breathing status.  You appear to still be unstable and require short-term additional acute care services that can safely be 
administered at the current facility until more stable and appropriate for a lower level of care. You do not 
require services at the LTACH that are not available at the current facility. 
 
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 the LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular reeducation (97112), self-care home 
management training (97535), and the therapeutic exercises (97530) rendered by the out-of-network (OON) 
provider on June 13, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the neuromuscular reeducation (97112), self-care home management training 
(97535), and the therapeutic exercises (97530) rendered by the out-of-network (OON) provider on June 13, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
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 you are appealing the denial for LTACH 
continued stay. The Plan denied your request. The Plan says the enrollee needs a doctor to see them every day 
and their needs are too much for an alternative level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that she is not 
currently receiving. The enrollee still requires acute care services before transitioning to a lower 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 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 laboratory services rendered on April 6, 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 procedure code 81455 is not supported. 
 
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 file shows that the 
specimen was not collected on the billed date of service. 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 laboratory services rendered on April 6, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 19, 2022. 
 
You asked the Plan to pay for the medical services. You say that the patient was not on hospice on this date of 
service. The Plan denied your request. The Plan says Original Medicare is responsible for this bill. 
 
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 May 11, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for medical services provided 
on May 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on May 6, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the review has 
determined that the documentation did not support that other means of transport (such as stretcher van, 
wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient. The 
documentation did not support that the patient needed the expertise, services and lifesaving and life-sustaining 
equipment that only a fully-equipped ambulance can provide for safe transport. The documentation did not 
support that the ambulance transport was medically reasonable and necessary for the patient. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on May 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on November 13, 
2021. 
 
You asked the Plan to pay for the services. You say that the records show that the appropriate diagnosis code 
was used. The Plan denied your request. The Plan says the diagnosis code is mismatched to the procedure 
modifier on the claim line. 
 
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 61645 is "Percutaneous arterial transluminal mechanical 
thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, 
fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(s)." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report describes a 
thrombectomy procedure performed for an occlusion, causing secondary problems. In this case, there is a more 
specific diagnosis code to support procedure performed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on November 13, 2021.