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

 
We decided that the Plan does not have to pay for the PCR (polymerase chain reaction) panel provided on April 
18, 2022. 
 
You asked the Plan to pay for the PCR panel. You say that this panel was medically necessary. The Plan denied 
your request. The Plan says the wound PCR panel was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the PCR panel. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the 68 year old enrollee has diagnoses of paroxysmal atrial fibrillation, diabetes mellitus, thoracic aortic aneurysm, hyperlipidemia, gout, fatty liver, iron deficiency anemia due to chronic blood loss, 
non-healing surgical wound. You provided a Wound PCR Panel. As an adjunct to wound cultures, culture-
independent investigation of the microbial DNA applying pyrosequencing,60 polymerase chain reaction 
(PCR)-denaturing gradient gel electrophoresis,61 and quantitative real-time PCR62 have identified a greater 
range of bacteria than traditional culture techniques. However, these identification techniques are costly and 
they require special training as well as instruments that make them less translational into clinical application. 
Recently, DxWound, a PCR-based microbial DNA analysis system, has been developed to provide accurate 
and sensitive detection of an array of microbes, including aerobic bacteria, anaerobic bacteria, and fungi. 
Moreover, the procedure is easy to handle with results available within 1 day. This comprehensive testing, 
although not rapid, has great potential in diagnosing wound infection. The Infectious Diseases Society of 
America (IDSA) recommends regarding "wounds" (termed skin and soft tissue infections in the IDSA 
guideline), typically recommends culture for most pathogens. Only a few strains of bacteria and viruses (such 
as taphylococcusaureus, coagulase-negative staphylococci, Enterococcus spp, MRSA, and streptococci) were 
recommended for nucleic acid testing with the majority of bacterial and fungal pathogens recommended for 
culture instead. The review has determined that the wound PCR panel provided on April 18, 2022, was not 
medically reasonable and necessary for the enrollee in this case. 
 
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 PCR panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the PCR (polymerase chain reaction) panel provided on April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies billed for 
date of service January 30, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you did not provide proof of delivery or a valid delivery 
ticket. 
 
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.  
 
 The record does not contain a valid proof of delivery for the supplies provided in this case. The only 
documentation of the order of these supplies is an unsigned and undated form that seems to indicate shipping. 
Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies 
billed for date of service January 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips. 
 
You asked the Plan to pre-approve additional non-emergency transportation trips. You say that you are running 
out of trips, and you have eight more appointments. The Plan denied your request. The Plan says the service is 
not covered beyond the 100 allotted one-way trips. 
 
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 100 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. Specifically, as of 
September 8, 2022, you have used or scheduled 100 one-way trips. Therefore, we decided that the Plan does 
not have to pre-approve additional non-emergency transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skin grafts (Epifix and Epicord) (CPT code(s): 
Q4186 and Q4187). 
 
You asked the Plan to pre-approve the skin grafts. You say that the skin grafts are necessary. The Plan denied 
your request. The Plan says the enrollee's records do not indicate that they have failed attempts at conservative 
wound therapy and the enrollee's records do not indicate if the blood flow problems to their leg are optimally 
treated. 
 
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 skin grafts. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the items/services at issue in this case are not medically reasonable or 
necessary. In this case, records do not indicate that the enrollee has failed attempts at conservative wound 
therapy and the records do not indicate if the blood flow problems to the leg are optimally treated. 
 
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 skin grafts have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skin grafts (Epifix and Epicord) (CPT code(s): Q4186 and Q4187).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialist office visit. You say that waiting the standard 30 days turnaround 
time (TAT) would jeopardize your health. The Plan denied your request. The Plan says the service can be 
provided by an in-network provider. 
 
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 
specialist office visit to be provided by an out-of-network (OON) provider.
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 you cannot walk or move and have been at the 
hospital for two months. You say you need to be transferred to the inpatient rehabilitation hospital The Plan 
denied your request. The Plan says the IRF care is not medically necessary, and your needs can be met at a 
lower level of care such as a skilled nursing facility (SNF). 
 
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 you were admitted for sepsis and atrial fibrillation. Your medical problems are stable, 
and there are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would greatly benefit from 
intensive, daily physical therapy. Additionally, they will need ongoing respiratory support. The Plan denied 
your request. The Plan says the enrollee does not meet the guidelines for long term acute care services. They 
can safely receive this care in another setting, such as the 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 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 LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service April 1, 
2022. 
 
You asked the Plan to pay for procedure code S2900. You say that you have provided medical records to 
support payment. 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 S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service April 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing rendered on 
December 20, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported correctly. 
 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  is not supported in the medical record. Specifically, this testing was not billed with the 
appropriate codes for cardiovascular disease screening. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for cardiac risk assessment genetic screening testing rendered on December 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 20, 2022, to 
January 25, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
principal diagnosis code of of J15.6 (Pneumonia due to other Gram-negative bacteria) was billed appropriately 
because this diagnosis was suspected at the time of discharge. The Plan denied your request. The Plan says the 
billed principal diagnosis code of of J15.6 (Pneumonia due to other Gram-negative bacteria) is not supported in 
the medical record. The principal diagnosis should be J18.9 (Pneumonia, unspecified organism) 
 
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 the principal diagnosis of J15.6 (Pneumonia due to 
other Gram-negative bacteria). 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 at the DRG originally billed. Our reviewer says that the principal diagnosis code of of J15.6 
(Pneumonia due to other Gram-negative bacteria) is not supported in the medical record. Our physician 
reviewer found the patient presented to the facility with the chief complaint of shortness of breath and rapid 
heart rate. Decreased breath sounds were documented and chest x-ray showed pneumonia. Pneumonia was 
diagnosed and treated; however, a diagnosis of gram-negative pneumonia cannot be made based on clinical 
signs and symptoms, due to the overlap with other types of pneumonia. Coding this should be supported by 
confirmatory data. For Gram negative pneumonia: a sputum gram stain, sputum culture or blood culture 
growing a gram-negative organism that is a pulmonary pathogen, or a positive urine antigen test for legionella 
(which is a gram-negative organism) must be present in documentation. As noted above, although the provider 
documented gram-negative pneumonia, consistent provider documentation support and clinical indicators 
related to the findings were not present within the health record for that diagnosis.  
 
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 inpatient hospital services provided on January 20, 2022, to January 25, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies billed for date 
of service April 2, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you did not provide a valid proof of delivery. 
 
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.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The only 
documentation of the order of these supplies is an unsigned and undated form that seems to indicate shipping. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies billed 
for date of service April 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 30, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for laboratory services provided to the enrollee on March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular cancer genomics (CGx) testing provided on 
December 28, 2021 billed with codes 81162, 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient 
in parallel. 
 
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 molecular cancer genomics 
(CGx) testing provided on December 28, 2021 billed with codes 81162, 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 77290 billed for dates of service April 18, 2022, to 
April 25, 2022. 
 
You asked the Plan to pay for code 77290. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this code is not separately payable from code 77301. 
 
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, we have confirmed that code 77290 
is a column II code to column I code 77301 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for code 77290 billed for dates of service April 18, 2022, to April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 8, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and 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 procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
March 1, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service was medically necessary and should be 
paid. The Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing billed with code 83789 for date of service March 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need rehab services; you became 
sick with COVID-19, and you need more respiratory and other therapies to get better. The Plan denied your 
request. The Plan says criteria for admission to the LTACH have not been met. Your medical needs are being 
met in the current acute 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 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 LTACH services.