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

 
We decided that the Plan does not have to pay for a Cxbladder triage test provided on December 13, 2021. 
 
You asked the Plan to pay for a Cxbladder triage test. You say that evaluation of urinary urothelil tumor 
markers may be considered during surveillance of high-risk non-muscle-invasive bladder cancer. You say that 
the Cxbladder triage performance was validated in a clinical study. You say that the requested testing is 
medically necessary. The Plan denied your request. The Plan says the requested testing is not a covered benefit 
for the diagnosis listed. 
 
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 a Cxbladder triage test. Our reviewer says 
that the Cxbladder triage test is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a listed diagnosis of asymptomatic microscopic hematuria. 
 
 
 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 Cxbladder triage test have not been met. Therefore, we decided that the Plan 
does not have to pay for a Cxbladder triage test provided on December 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a cardiac rhythm monitor. 
 
You asked the Plan to pre-approve the cardiac monitor implantation. You say that this should be approved as it 
is medically necessary. The Plan denied your request. The Plan says there is no medical need for this 
procedure. 
 
The Plan follows Medicare rules. Medicare rules say that implantation of a cardiac event monitor may be 
covered for the indications listed in the rules section of this decision.  
 
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 cardiac monitor implantation. Our 
reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer 
found while the patient has a history of atrial fibrillation, there is no documentation provided to suggest a 
history of unexplained syncope, cryptogenic stroke or any other apparent indication for an implanted loop 
recorder (ILR). In summary, there is insufficient documentation to support the medical necessity for insertion 
of an ILR in this patients clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the cardiac monitor implantation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve implantation of a cardiac rhythm monitor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that the trips are necessary because you need to 
go to dialysis three times per week in order to live. The Plan denied your request. The Plan says you have used 
up this benefit. No further trips can be approved. 
 
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 10 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 pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable 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 follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are 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 a portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has required supplemental oxygen since COVID-19 pneumonia in November 2021, 
and has been readmitted to the hospital more recently. There is no diagnosis of chronic obstructive pulmonary 
disease (COPD), thoracic restrictive disease, or neuromuscular disease. The enrollee does not have chronic 
carbon dioxide (CO2) retention, so criteria are not met for ventilatory support during sleep, and Medicare does 
not pay for a ventilator when used as bilevel positive airway pressure (bipap). 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis, solid organ neoplasm, 
DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene 
rearrangements, microsatellite instability and tumor mutational burden (CPT code 0037U) provided on 
December 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered. 
 
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 laboratory services have not been met. The next generation 
sequence testing (NGS) testing panel performed included testing for the FANCC gene. Testing for this gene is 
not a Medicare benefit and is statutorily excluded service. In addition to single gene testing, panels that include 
the FANCC gene are statutorily excluded service. Therefore, we decided that the Plan does not have to pay for 
targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for 
sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor 
mutational burden (CPT code 0037U) provided on December 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON CT scan. You say that this imaging is medically necessary. The 
Plan denied your request. The Plan says this imaging can be provided in-network. There is no need for OON 
referral. 
 
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 
a computed tomography (CT) scan to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device (CPT code 0266T). 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that the device is really needed for the 
enrollee since they have heart failure, and the enrollee has had the device since two (2) years covered with 
Medicare. The Plan denied your request. The Plan says the Barostim Neo device is considered unproven and is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Barostim Neo device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo device (CPT code 0266T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 functional level foot (L5981, L5986). 
 
You asked the Plan to pre-approve a K3 functional level foot and ankle. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the enrollee does not satisfy 
the K3 functional level required for the requested prosthetic foot. 
 
The Plan follows Medicare rules. Medicare rules say that the requested prosthetic foot requires a functional 
level of 3 or above. 
 
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 K3 functional level foot. Our reviewer 
says that the requested prosthetic foot is not medically reasonable and necessary. Our physician reviewer found 
that you are a 58-year-old male with a medical history including hyperlipidemia, diabetes mellitus, chronic 
lung disease and a previous left-sided below-the-knee-amputation who is requesting an advanced foot and 
ankle. A level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical of the 
community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. In this case, the 
documentation does not indicate that you are a K3 level ambulator. Therefore, you would not require the 
requested advanced foot and ankle system. 
 
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 K3 functional level foot have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a K3 functional level foot (L5981, L5986).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided from 
February 22, 2022, to February 24, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you only went to one visit 
so the other two should be covered. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $20 
copayment for each Medicare-covered physical, occupational or speech language therapy visit. 
 
 
 
 You have been asked to pay a total of $60 ($20/visit x 3 visits = $60) copayment for the physical therapy visits. 
Physical therapy visits fall within the Outpatient rehabilitation 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 physical therapy visits provided from February 22, 2022, to February 
24, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (81479) provided November 11, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
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. The denial rationale provided by the plan refers to coverage rules pertaining to 
surgical assistants. The plan's denial rationale is irrelevant to the genetic testing services at issue. Therefore, we 
decided that the Plan has to pay for genetic testing (81479) provided November 11, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the CardioMEMS device has been determined to be of uncertain 
value. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients clinical management. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microslide consultation (88321) and two (2) office 
visits (99205, 99215) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a microslide consultation and 2 office visits. You say that you are requesting 
reconsideration of the denied services. The Plan denied your request. The Plan says there are in-network 
providers available for these services. The Plan allows for OON coverage for emergency services or when there 
are no INN providers available. 
 
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.  
 , we decided that the Plan does not have to pre-approve a microslide consultation (88321) and two (2) office 
visits (99205, 99215) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the assisted living services provided from 
October 12, 2021, through November 30, 2021. 
 
You asked the Plan to issue reimbursement. 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 Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. The rules say that assisted living 
facilities are not eligible to enroll in the Medicare program. Additionally, the rules say that custodial care is not 
covered.  
 
 
 We looked at the case file and Medicare rules. The rules state that Medicare pays for services only when they 
are furnished by a provider or supplier enrolled in the Medicare program. The services in this case were 
rendered by an assisted living facility that is not eligible to enroll in Medicare. Additionally, Medicare rules say 
that custodial care is not a covered benefit. Therefore, we decided that the Plan does not have to issue 
reimbursement for the assisted living services provided from October 12, 2021, through November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 83520 and 83631) 
provided on February 3, 2021. 
 
You asked the Plan to pay for the laboratory 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. Medicare rules say that 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 laboratory 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 the laboratory services (CPT code(s): 83520 and 83631) provided on 
February 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve a pneumatic compression device. 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 follows Medicare rules. Medicare rules say that a PCD coded as E0650 or E0651 is covered for both 
primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema 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 a pneumatic compression device. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the review indicates 
that the appeal states that the enrollee was provided with pneumatic compression pump and sleeves on 
February 10, 2022. The progress has been monitored and the provider states that the enrollee is compliant and 
has been tolerating treatments well and has experienced improvement. The review has determined that the documentation provided does not include all of the requirements above. The enrollee does not meet the 
coverage criteria detailed in the LCD. 
 
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 pneumatic compression device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compression device.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for electroencephalogram (EEG); including recording awake and drowsy 
(95816) provided on October 21, 2021. 
 
You asked the Plan to pay for the EEG. You say that the service should be covered. The Plan denied your 
request. The Plan says that the claim processed correctly. The Plan also says that the primary plan's allowable 
amount is greater than the fee maximum. 
 
The Plan must follow Medicare rules. The rules state that Medicare secondary payment amounts are 
determined by a formula and whichever is the lowest. 
 
In this case, the lowest payment is based on the higher of the Medicare payment amount or the primary payers 
allowable charge minus the amount actually paid by the primary payer. The record shows that the primary 
payers allowable charge was $779.63 for the service. The record shows that they paid $623.46. The remaining 
payable amount is $155.86. Therefore, we decided that the Plan has to pay for electroencephalogram (EEG); 
including recording awake and drowsy (95816) provided on October 21, 2021.  
 
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.