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

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (CPT code 
81455) provided on March 24, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. 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. Targeted genomic sequence 
analysis panel, code 81455, is non-covered by Medicare. Genetic testing procedures submitted with code 81455 
are unlikely to impact therapeutic decision-making in the clinical management of the enrollee and will be 
denied automatically as not medically necessary. The claim was billed with a date of service inconsistent with 
Medicare rules governing laboratory services. The specimen was collected on March 15, 2022, rather than the 
billed date of service March 24, 2022. Therefore, we decided that the Plan does not have to pay for the targeted 
genomic sequence analysis panel (CPT code 81455) provided on March 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from acute 
rehabilitation to optimize her level of functioning prior to returning home. You also say that further delay in 
care will have a detrimental effect on the enrollee's safety and ability to recover to the fullest extent. The Plan 
denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a lower 
intensity and alternate setting such as a skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for transfer to the 
LTACH where care can be given and the appropriate medical oversight. The Plan denied your request. The 
Plan says the request is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar decompression and fusion services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is losing his quality of life. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 requested services. Our physician 
reviewer found that the medical records do not show any evidence of instability of the spine. Also, there is no 
documented surgical plan as to what levels are going to be fused. Therefore, the request is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar decompression and fusion services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 12, 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 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 May 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve 5 additional home health physical therapy visits. You say that the requested 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage have not been met because the requested services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 5 additional home health physical 
therapy visits. Our reviewer says that the requested services are not medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is able to continue to improve or maintain with repetitive 
exercise and does not require continued unique input from a skilled therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 additional home health physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 5 additional home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 March 3, 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 clinical documentation shows that you have an IRF compliant diagnosis and 
functional impairments with evaluating therapists recommending intense therapy however, there are no active comorbidities that would require continued inpatient hospitalization during rehabilitation. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service May 12, 
2021. 
 
You asked the Plan to pay for procedure code 99601. You say that you disagree with the denial. 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 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology (CPT code G0416) provided on 
February 18, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. 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. The billed procedure code G0416 
have a physician Fee Schedule PCTC indicator of 1 and the claim a POS of 22  Outpatient hospital. Payment 
is not made under the physician fee schedule for TC services furnished in institutional settings where the TC service is bundled into the facility payment. The Medicare rule for payment of this claim has not been met as 
the professional interpretation of a diagnostic test must be separately billed with modifier  26 by the 
interpreting physician. Therefore, we decided that the Plan does not have to pay for the surgical pathology 
(CPT code G0416) provided on February 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve block (64454) provided from February 
10, 2022, to February 25, 2022. 
 
You asked the Plan to pay for the genicular nerve block. You say that current procedural terminology code 
64454 is covered per the Plan's policy. The Plan denied your request. The Plan says the clinical value and 
effectiveness of a genicular nerve block in the setting of knee osteoarthritis have not been demonstrated in the 
peer-reviewed literature. 
 
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 genicular nerve block. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental/investigational and there are ongoing 
clinical trials to determine the role of genicular blocks and genicular nerve radiofrequency ablation in the 
management of osteoarthritis of the knee. 
 
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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pay for the genicular nerve block (64454) provided from February 10, 2022, to February 
25, 2022.
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. The Plan denied your request. The Plan says 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 physician 
reviewer found that you were admitted to the acute care hospital with leukocytosis in the setting of 
cholecystitis. The record indicates that you have ongoing medical issues and still require acute care services 
before transitioning to a lower level of care. You continue to receive acute care services, and these have not 
been denied. The medical record does not indicate that you require services that you are not currently receiving 
but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The 
requested service cannot be recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis and the foot heel stabilizer provided 
on May 25, 2022. 
 
You asked the Plan to pay for the ankle foot orthosis and the foot heel stabilizer. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the items rendered are not payable. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the documentation submitted did not sufficient support the billed 
supply codes. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis and the 
foot heel stabilizer provided on May 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology service (CPT code 88305) provided on 
October 28, 2021. 
 
You asked the Plan to pay for the pathology service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the pathology service have not been met. The records show the 
enrollee was an outpatient on this date of service and that the facility rendered procedure 88305 on the date of 
service October 28, 2021. Furthermore, another provider rendered service code 88305 on the same date of 
service and place of service 22 - Outpatient Hospital. Per the Medicare guidelines, the billed procedure code 
88305 has a physician Fee Schedule PCTC indicator of 1. Therefore, we decided that the Plan does not have to 
pay for the pathology service (CPT code 88305) provided on October 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure has not been shown to be 
clinically effective. The Plan denied your request. The Plan says the enrollee meets the indications for use. 
 
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 requested services. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to show its efficacy. 
Therefore, the request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gastrointestinal pathogen (GIP) panel, 6-11 targets 
(87506) provided May 31, 2022. 
 
You asked the Plan to pay for the GIP panel, 6-11 targets. You say that the testing was medically necessary. 
The Plan denied your request. The Plan says expanded panel testing is only indicated when targeted panel 
testing is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that GIP testing is limited to no more than 5 bacterial 
pathogen targets when not testing for Clostridium difficile. 
 
We looked at the file and Medicare rules. Testing for Clostridium difficile was not performed in this case. 
Therefore, testing is for 6-11 targets is not covered. Based on this information, we decided that Medicare rules 
for coverage of the GIP panel, 6-11 targets have not been met. Therefore, we decided that the Plan does not 
have to pay for the gastrointestinal pathogen (GIP) panel, 6-11 targets (87506) provided May 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that enrollee would benefit from IRF to improve overall 
functional mobility and safety prior to returning home. You say that the enrollee is at high risk for falls and 
infection. The Plan denied your request. The Plan says that IRF is not medically necessary. The enrollee can 
safely receive the services they need in another setting, such as a 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 the enrollee does not require treatment by multiple therapies. While the medical records support a need for physical and/or occupational therapy, there is no documented need for IRF. 
Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. You say that you had a 
recent heart surgery and you are unable to walk, much less drive. You say that you have a post-surgery follow 
up appointment on November 14, 2022 and need the transportation to get to this appointment. The Plan denied 
your request. The Plan says the member has exhausted all the 20 transportation trips for the year 2022. 
 
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 provide coverage for additional routine transportation trips.