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

 
We decided that the Plan has to pay for assistant at surgery services for a knee arthroplasty procedure (27447) 
provided on March 14, 2022. 
 
You asked the Plan to pay for assistant at surgery services. You say that the assistant at surgery services at 
issue were a medical necessity for you. The Plan denied your request. The Plan says that rules for payment for 
assistant at surgery services have not been met because the provider at issue is not an eligible provider. 
 
The Plan must follow Medicare rules. The rules 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 denied because the provider at issue is not an eligible 
provider (a physician, PA, NP, or CNS). We checked Medicare records and found that the provider at issue is a 
surgical physician assistant (PA). A PA is an eligible provider for assistant at surgery services. The Plan has 
not provided any other rationale for denial. It is the Plan's responsibility to substantiate its denial with evidence. 
In this case, the denial has not been substantiated, so we must find in your favor. Therefore, we decided that the 
Plan has to pay for assistant at surgery services for a knee arthroplasty procedure (27447) provided on March 
14, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring of an external continuous pulmonary 
fluid monitoring system services provided on April 13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the remote monitoring of an external continuous pulmonary fluid monitoring 
system services. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says 
the services rendered are not a covered benefit. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the remote monitoring of an external continuous 
pulmonary fluid monitoring system services provided on April 13, 2022, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology examination provided on May 26, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for pathology examination. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the enrollee must receive care from a 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for pathology examination provided on May 26, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cardiovascular hereditary panel and a 
comprehensive pharmacogenomic (PGx) panel provided on May 26, 2022. 
 
You asked the Plan to pay for laboratory testing panels. You say that these tests were medically necessary and 
were ordered by the enrollee's physician. The Plan denied your request. The Plan says these tests were 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 laboratory testing panels. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, there is no documentation from the provider indicating the drugs being 
considered for use, and no documentation to show how the results of these tests will impact the enrollee's 
treatment. This review has determined that both panels were not medically necessary according to the criteria 
laid out in the LCDs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory testing panels have not been met. Therefore, we decided that the Plan 
does not have to pay for the comprehensive cardiovascular hereditary panel and a comprehensive 
pharmacogenomic (PGx) panel provided on May 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 5, 2022, billed with 
codes 81225 and 81226. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 5, 2022, billed with codes 81225 and 81226.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81455) provided on August 24, 2021. 
 
You asked the Plan to pay for laboratory testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing (81455) 
provided on August 24, 2021.
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 the enrollee is medically stable for transfer to IRF. 
The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that the enrollee will be able to fully participate in 
- and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI) benefit. 
 
You asked the Plan to pre-approve the SSBCI benefit. You say that you did not get your form for this benefit in 
on time. You also say that you need this benefit. The Plan denied your request. The Plan says all of the SSBCI 
requirements have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefit have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI) benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cryoablation (64640). 
 
You asked the Plan to pre-approve cryoablation. You say that this should be covered. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that non-thermal modalities for facet joint 
denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and 
cryoablation are not coverable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of cryoablation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
cryoablation (64640).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 
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. Medicare rules say that Rituxan is covered when specific criteria are met. 
 
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 enrollee has inflammatory 
pachymeningitis. The noted diagnosis is not an enumerated condition for which Rituxan is covered. The 
services are therefore not reasonable or 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 Rituxan.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
May 19, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for in-network outpatient hospital services.  
 
You have been asked to pay $120.08 for outpatient hospital services, which is less than the standard cost 
sharing amount. This item/service falls within the outpatient hospital services benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for outpatient hospital services provided on May 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31238 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 31238. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 31238 is bundled into payment for code 99232. 
 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 99232 
is a column II code to column I code 31238. 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 31238 billed for date of service July 26, 2022.
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 are appealing with records. The Plan denied 
your request. The Plan says the denial of IRF care is correct. 
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is no documented need for intensive rehabilitation services. There is not a reasonable expectation that the enrollee 
will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in 
an IRF. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says The IRF services you 
are requesting do not meet the requirements for approval and the enrollee can safely receive the services 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 the enrollee's medical and rehabilitation needs do not require the intensive 
interdisciplinary approach provided in acute inpatient rehabilitation. The enrollee does not require 
rehabilitation nursing or treatment by multiple therapies. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty surgery (22514). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the enrollee's current low back pain is 
primarily due to acute fracture and not chronic pain. Please reconsider this enrollee's care. The Plan denied 
your request. The Plan says the medical necessity criteria has 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 the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records show that there is bone retropulsion at the fracture site which is a 
contraindication to kyphoplasty. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve kyphoplasty surgery (22514).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skyrizi. 
 
You asked the Plan to pre-approve Skyrizi. You say that [Enter appellant's argument from appeal letter, e.g. 
"...you need SNF care."] The Plan denied your request. The Plan says the enrollee's plan does not have a 
Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs 
do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Skyrizi.  
 
Benefits for Skyrizi 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 18, 2021, to July 
28, 2021, 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 these 
services were necessary and this diagnosis is supported in the medical record. The Plan denied your request. 
The Plan says the billed DRG is not supported, as the diagnosis of acute respiratory failure with hypoxia 
(J96.01) is not supported in the medical record for this inpatient admission. 
 
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 acute respiratory failure with hypoxia (J96.01). 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 this diagnosis is not supported. Our physician reviewer found that 
there was no clinical or laboratory evidence of acute respiratory failure with hypoxia in the medical record. 
 
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 July 18, 2021, to July 28, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis, 51 or greater genes 
(81455) provided June 14, 2022. 
 
You asked the Plan to pay for the Tempus xT Solid Tumor and Heme CGP Panel. You say that this letter and 
the attached documents support the medical necessity of the tests requested, to assist in the treatment, prognosis 
and diagnosis for this type of cancer. The Plan denied your request. The Plan says the diagnosis provided with 
the claim was not on the Medicare LCD. 
 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. Per the LCA A56867, any diagnosis code not listed does not support 
medical necessity. The records show that the diagnosis is C85.83, which is not listed as an ICD-10-CM 
diagnosis code that supports medical necessity. Based on this information, we decided that Medicare rules for 
coverage of the Tempus xT Solid Tumor and Heme CGP Panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the targeted genomic sequence analysis, 51 or greater genes (81455) provided 
June 14, 2022.