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

 
We decided that the Plan has to pay for FoundationOne CDx (F1CDx) testing (0037U) billed for date of 
service March 3, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says that the date of service for a clinical laboratory 
test or the technical component of physician pathology service must be the date the specimen was collected. 
The record shows that the specimen was collected on February 16, 2022, rather than the billed date of service 
of March 3, 2022. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory services should be reported with 
the date of specimen collection as the date of service; however, there are three exceptions to this rule. The rules 
also say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE 
information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not acknowledged nor addressed the exceptions to the 
applied rule. The specimen in this case was a piece of live tissue collected in a hospital setting for cancer-
related testing. It is likely that an exception has been met in this case, which would mean that the correct date to 
report would be the date the testing was performed: March 3, 2022. Therefore, we decided that the Plan has to 
pay for FoundationOne CDx (F1CDx) testing (0037U) billed for date of service March 3, 2022.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2022, billed with 
codes 81479, 81401, 81225, 81227, 81226, 81231, 81400, 81291, 81240, 81328 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the record. The Plan denied your request. The Plan says this claim was not reported in accordance 
with Medicare billing guidelines. 
 
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 27, 2022, billed with codes 81479, 81401, 81225, 81227, 81226, 81231, 81400, 81291, 81240, 81328 and 
81355.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650). 
 
You asked the Plan to pre-approve the spinal cord stimulator. You say that the stimulator is medically 
necessary. The Plan denied your request. The Plan says a trial of conservative therapy is required before a 
spinal stimulator can be considered. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulator therapy should be considered 
as a late option after more conservative attempts, such as medications, physical therapy, psychological therapy, 
or other modalities have been tried. 
 
 
 
 
 
 
 
 
 
 
 
 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 spinal cord stimulator. Our reviewer 
says that the spinal cord stimulator is not medically necessary. Our physician reviewer found the enrollee has 
not had chiropractic, acupuncture, or other conservative therapy documented. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator (63650).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the CardioMEMS device is considered unproven and is 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 pre-approve the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (CPT code 33289).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 3, 2022, billed with 
codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. 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 guidelines. 
 
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 3, 2022, billed with codes 0031U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232 and 81355.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 27, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 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 code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect testing (0012M) provided on May 12, 
2022. 
 
You asked the Plan to pay for the Cxbladder Detect. You say that this test was medically necessary and is 
covered. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder Detect have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder Detect testing (0012M) provided on May 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93320 billed for date of service June 1, 2022. 
 
You asked the Plan to pay for procedure code 93320. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 93320 is bundled into 
payment for code 93308.  
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 93320 
is a column II code to column I code 93308. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93320 billed for date of service June 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care starting on October 30, 
2022. 
 
You asked the Plan to pre-approve acute inpatient hospital care starting October 30, 2022. You say that the 
services are medically necessary. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
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 acute inpatient hospital care starting 
October 30, 2022. Our reviewer says that the documentation does not support that the criteria for inpatient 
admission are met in this case. Our physician reviewer found it was not expected that the enrollee would 
require hospital services that would likely cross 2 midnights due to the low severity and low complexity of the 
presentation at the time of admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care starting October 30, 2022, have not been met. 
Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care starting on 
October 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in volume-assured pressure 
support (VAPS) mode with or without auto-expiratory positive airway pressure (EPAP) (AE) that could be 
delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found LCD L33800 states: Claims for ventilators used to provide CPAP or bi-level CPAP therapy 
for conditions described in this RAD policy will be denied as not reasonable and 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that the enrollee was an inpatient at the time the services were provided. We looked at the file 
and the rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for 
services furnished to a beneficiary. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement 
of the facility. 
 
Payment for this service would have been included under the facility claim. Payment to you for this service is 
the responsibility of the facility. 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 the 
laboratory services provided on January 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 8, 2021, to 
December 15, 2021, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
physician appropriately made this diagnosis based on a hands-on physical evaluation and all other clinical 
information available. You say that you disagree with removing the principal diagnosis code and changing the 
DRG. The Plan denied your request. The Plan says diagnosis code A41.9 is not supported. 
 
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 code A41.9, defined as sepsis, 
unspecified organism. 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 documentation does not support principal 
diagnosis code A41.9. Our physician reviewer found that although the provider documented sepsis, reasonable 
support within the health record must be present 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 December 8, 2021, to December 15, 2021, at the DRG originally 
billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in tub (E1399). 
 
You asked the Plan to pre-approve a walk-in tub. You say that you have fallen several times and need this item. 
The Plan denied your request. The Plan says the requested tub does not primarily serve a medical purpose and 
is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in tub (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided 
April 14, 2022 to May 13, 2022. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that the medical records 
provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this item 
is not a medically necessary. 
 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. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a water circulating heat pad with pump (E0217) provided April 14, 2022 to May 13, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have severe urinary incontinent 
problems that multiple procedures have not corrected. You also say that you have constant bladder infections, 
and you spend a lot of money on these supplies, and you really need them. The Plan denied your request. The 
Plan says the requested items are not a covered benefit with your plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, a scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the enrollee needs to be able to leave the 
hospital with the requested scooter. She is oxygen dependent and cannot walk more than 20 feet. The Plan 
denied your request. The Plan says the power scooter that you are requesting does not meet the requirements 
for approval. The Plan does not have a home assessment, if the enrollee is able to accomplish her ADLs, 
specialty evaluation by physical therapy/occupational therapy, or a 7-element order. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show that you have a mobility deficit that impairs your participation in MRADLs. The file 
also does not show that you have completed the necessary evaluations for approval of the requested scooter. 
This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power operated vehicle, a scooter (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoskeletal ankle foot system, microprocessor 
controlled feature, dorsiflexion and/or plantar flexion control, includes power source (CPT code L5973). 
 
You asked the Plan to pre-approve the service. You say that the item is necessary. The Plan denied your 
request. The Plan says the request for microprocessor foot does not meet Medicare criteria as 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 the service. Our physician reviewer 
found the requested K3 foot cannot be approved, as it is not reasonable and necessary. Request of new 
prostheses exceeds your functional need. The review has determined that the medical records provided do not 
meet the requirements listed in the LCD for Medicare coverage. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or 
plantar flexion control, includes power source (CPT code L5973).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimzia Kit (CPT code J0717). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says there is no documentation that the enrollee has not had an inadequate response, 
adverse event, or contraindication to a trial of the preferred agents: Avsola, Remicade, or Simponi Aria. 
 
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 the medication. Our physician reviewer 
found there is no documentation provided indicating that the Plans required drug(s) would 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Cimzia Kit (CPT code J0717).