Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench with rollers and a powered toilet seat 
lift. 
 
You asked the Plan to pre-approve a transfer bench and a powered seat lift. You say that you need these items 
to be independent at home. The Plan denied your request. The Plan says the requested items do not meet 
criteria because the transfer bench with rollers and powered toilet seat lift do not serve a medical purpose. 
 
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 transfer bench with rollers and a powered toilet seat lift.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 is intact in his upper extremities. He does have an amputation and a 
Charcot foot and is primarily deconditioned chronically with an acute exacerbation secondary to fall and long 
lie. He does not require intensive rehabilitation as his progress with short periods of acute hospital 
rehabilitation services show. Nor does he have complex or specialized rehabilitation needs again as his short 
rehabilitation course in the hospital showed. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 16, 2021 billed with 
codes 81206, 81210, 81235, 81272, 81275, 81276, 81301, 81311, and 81321. 
 
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 this is incorrect coding. 
 
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 16, 2021 billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81301, 81311, and 81321.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on April 7, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart device. 
 
You asked the Plan to pre-approve an Optimizer Smart device. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have 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 an Optimizer Smart device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, cardiac contractility 
modulation (CCM) remains the subject of multiple studies examining long-term efficacy, as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, it is not 
considered that the CCM system is 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 an Optimizer Smart device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Optimizer Smart device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specimen validity testing provided to the enrollee on 
November 12, 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 cannot be reimbursed separately. 
 
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 testing 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 specimen validity testing provided to the enrollee on November 12, 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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have 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 that the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a lower level of care 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 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. You say that you need to strengthen your lungs and be removed 
from oxygen so you can return to the lifestyle you had before. The Plan denied your request. The Plan says the 
denial of authorization for 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 you are medically stable and do not require rehabilitation physician supervision 3 times per week in an intensive rehabilitation setting. While you may benefit from continued physical and/or 
occupational therapy, your needs can be met in a lower intensity setting such as in-home with 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is needed to be able to walk again. The Plan 
denied your request. The Plan says care can be received in a different setting, like home health. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the criteria for SNF has not been met. You are functioning with home care. You 
are able to improve with repetitive exercise and support from non-skilled personnel. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on APril 11, 2022. 
 
You asked the Plan to pay for the urine PCR panel testing. 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. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and  
sensitivity. The PCR testing is considered unproven 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the urine polymerase chain reaction (PCR) panel testing provided on APril 11, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the next generation sequence (NGS) testing panel provided on February 
23, 2022. 
 
You asked the Plan to pay for the NGS testing panel. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that panels that include the FANCC and BLM genes are a statutorily 
excluded service. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the NGS 
testing panel have been met. Therefore, we decided that the Plan has to pay for the next generation sequence 
(NGS) testing panel provided on February 23, 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 is responding well to skilled therapy. The enrollee is at a functional level 
which does not require intensive rehabilitation. She may improve walking and transfer with repetitive exercise. 
She clearly has responded well without physiatry oversight. 
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the facility you are currently at is unable to provide 
you with the therapies you need. The Plan denied your request. The Plan says the submitted clinical 
information does not support the medical necessity of care requested. 
 
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 are able to transfer and walk at supervision level. You do not have acute medical 
conditions which require a prolonged hospital stay.  
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 pay for surgical services (procedure codes 11603, A4550) provided 
to the enrollee on October 27, 2021. 
 
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 codes were not correctly billed. 
 
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 the denied codes is: 
 
CPT 11603: 
 
Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm 
 
HCPCS A4550: 
 
Surgical trays  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 11603 was reported with 
modifier 25 - significant separately identifiable evaluation and management service by the same physician or 
other qualified health care professional on the same day of the procedure or other service. In this case, modifier 
25 cannot be verified, as the evaluation and management procedure is related to the procedure performed 
during the same session. In terms of A4550, the surgical tray is considered part of the surgical procedure and 
would not be reported separately. Therefore, this procedure code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure codes 11603, A4550) provided to the enrollee on October 27, 
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 have no complicating factors which would prohibit recovery from a hip fracture 
with mild anemia post-op. Hip fracture rehabilitation does not require frequent physiatry oversight or intensive 
therapy. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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 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 a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found thus, using the HCPCS codes for 
continuous positive airway pressure (CPAP) (E0601) or bi-level PAP (E0470, E0471) devices for a ventilator 
(E0465, E0466, or E0467) used to provide CPAP or bi-level PAP therapy is incorrect coding. Claims for 
ventilators billed using the CPAP or bi-level PAP device HCPCS codes will be denied as incorrect coding. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.