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

 
We decided that the Plan has to pay for Tempus Homologous Recombination Deficiency (HRD) (81479) billed 
for date of service May 20, 2022. 
 
You asked the Plan to pay for Tempus HRD testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that this claim was submitted 
with an incorrect date of service, as the date of service reported for a clinical laboratory test or technical 
component of physician pathology service must be the date the specimen was collected. 
 
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 possible 
exceptions to the general rule. However, the evidence shows that the specimen in this case included a tumor 
tissue sample collected in a hospital setting which was likely collected during a surgical hospital procedure. It 
is very likely that an exception has been met in this case. Therefore, we decided that the Plan has to pay for 
Tempus Homologous Recombination Deficiency (HRD) (81479) billed for date of service May 20, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve advanced imaging services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON advanced imaging services. You say that the requested imaging is 
medically necessary The Plan denied your request. The Plan says there are network providers who are able to 
supply the advanced imaging services being requested. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
advanced imaging services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that 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 were admitted for back pain, diarrhea, and urinary tract infection. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) a harness (E2313) and 
an electrical connection between the wheelchair controller and two or more motors (E2311). 
 
You asked the Plan to pre-approve the expandable controller, the harness, and the electrical connection 
between the wheelchair controller and two or more motors. You say that the records provided support the need 
for items which remain in dispute. The Plan denied your request. The Plan says there is no medical need to 
control the power options through a joystick. 
 
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 expandable controller, the harness, and the electrical connection between the wheelchair controller and two or more motors. Our reviewer says that 
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested items exceed the enrollee's medical needs. The enrollee does not require a ventilator, or 
non-proportional input devices. The enrollee does not require a separate display, other electronic devices, or an 
attendant control. The enrollee has power options on the wheelchair but does not need to control the power 
options through a joystick. The enrollee's upper extremity function with independence in eating supports that 
they can control any power options through their own switches. 
 
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 expandable controller, the harness, and the electrical connection between the 
wheelchair controller and two or more motors have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller (E2377) a harness (E2313) and an electrical connection between 
the wheelchair controller and two or more motors (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic tooth #'s 4, 6, 8, 23 
and 26 (D6740 x2), pontic - porcelain/ceramic tooth #'s 5, 7, and 13 (D6245 x1), surgical placement of implant 
body tooth #'s 3, 12, 14 and 30 (D6010 x2), custom fabricated abutment  tooth #'s 3, 12, 14 and 30 (D6057 x2), 
bone replacement graft for ridge preservation - per site tooth #30 (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that your oral health is rapidly declining and 
you need the procedure done as soon as possible. The Plan denied your request. The Plan says the denial is 
correct, because these services are not covered by the Plans dental benefits or they are covered but the 
coverage benefit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply.  
 
The retainer crown - porcelain/ceramic (D6740 x2), is denied because the limit is 3 and 2 were approved on the 
original request. 
 
The pontic - porcelain/ceramic (D6245 x1) is denied because the limit is 3 and 3 were approved on the original 
request. 
 
The surgical placement of implant body tooth (D6010 x2) is denied because the limit is 2 and 2 were approved 
on the original request. 
 
The custom fabricated abutment (D6057 x2) is denied because the limit is 2 and 2 were approved on the 
original request. 
 
The bone replacement graft for ridge preservation - per site (D7953) is denied because it is not covered by the 
Plans dental benefits. 
 
The Plan agreed to pre-approve the retainer crown - porcelain/ceramic (D6740 x3), core buildup, including any 
pins (D2950 x3), surgical placement of implant body (D6010 x2), abutment supported retainer (D6068 x2), a 
retainer crown - porcelain/ceramic (D6740 x3), pontic - porcelain/ceramic (D6245 x3), custom fabricated 
abutment (D6057 x2), porcelain/ceramic crown (D6058 x2), and bone graft at time of implant placement 
(D6104 x1).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Choice StealthCage and Osteo Amp allograft. 
 
You asked the Plan to pre-approve the Choice StealthCage and Osteo Amp allograft. You say that this 
procedure is medically reasonable and necessary. The Plan denied your request. The Plan says these procedures 
during the approved spine surgery are 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 Choice StealthCage and Osteo Amp 
allograft. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested StealthCage and Osteo Amp allograft are 
experimental in spine surgery. They are not medically needed during the ordered spine surgery. Conventional 
structural allograft may be safely used.  
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 Choice StealthCage and Osteo Amp allograft have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Choice StealthCage and Osteo Amp allograft.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 3, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 19, 2022, through 
June 17, 2022. 
 
You asked the Plan to pay for home health services. You say that verification of the NOA submission is 
attached, and the claim should be reprocessed for payment. The Plan denied your request. The Plan says the 
claim was submitted with the incorrect admission date. 
 
The Plan must follow Medicare rules. Medicare rules say that the admission date on the NOA should match the 
admission date on all subsequent claims.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the claim was submitted with the incorrect 
admission date. Therefore, we decided that the Plan does not have to pay for home health services provided 
from May 19, 2022, through June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99202, 99212) provided on April 25, 2022 
and May 26, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visits (99202, 99212) provided on April 25, 2022 and May 26, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental service (D6545) is not covered under the 
member's contract under any normal circumstances. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on March 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the microprocessor knee and K3 foot (CPT code(s): 
L5828, L5845, L5848, L5856, L5981, L5986). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the microprocessor knee and K3 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 items. Our physician reviewer 
found there is inadequate documentation that the microprocessor knee and K3 foot at issue in this case meet all 
Medicare criteria for medically reasonable and necessary for the enrollee per the LCD. Provided records 
document a current diagnosis of dependence on a wheelchair as of November 18, 2022. Records document the 
enrollee was approved for a group 1 power mobility device as of November 4, 2022, due to a personal mobility 
deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, 
grooming and bathing in customary locations within the home and the enrollee's mobility deficit cannot be 
helped by the use of a walker, cane or manual wheelchair. These mobility deficits are not consistent with a K3 
ambulatory level to meet criteria for the microprocessor knee and K3 foot. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
microprocessor knee and K3 foot (CPT code(s): L5828, L5845, L5848, L5856, L5981, L5986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #20 and #21 provided on 
May 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the core 
buildup is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) for tooth #20 and #21 provided on May 20, 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
does not support that he would meet criteria for admission to an acute inpatient rehabilitation facility. There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his 
functional status. The enrollee can receive further services at a lower 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (CPT code J7326). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred step therapy device(s): Durolane, 
Monovisc, or Synvisc-One. The Plan states there is no indication the Plan's preferred agent(s) would likely be: 
less effective, and/or cause adverse effects for the enrollee. 
 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 indication that the enrollee has tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the Plan's 
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 Gel-One (CPT code J7326).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid coded 87801 
provided on July 7, 2022.  
You asked the Plan to pay for the infectious agent detection by nucleic acid. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed 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 test at issue in this appeal, the infectious agent detection by nucleic acid, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the infectious agent detection by nucleic acid coded 87801 provided on July 
7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupressure services billed with code 99199 you received 
from January 5, 2022, to May 19, 2022. 
 
You asked the Plan to pay for code 99199. You say that you were told that acupuncture is a covered benefit. 
The Plan denied your request. The Plan says it has paid for the acupuncture services, but the acupressure 
services billed with code 99199 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for acupuncture services billed 
with the following codes:  97810, 97811, 97813, 97814, 20560, and 20561. The acupressure services you 
received (code 99199) are not listed as covered acupuncture services under Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99199 have not been met. Therefore, we decided that the Plan does not have to pay for the 
acupressure services billed with code 99199 you received from January 5, 2022, to May 19, 2022.