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, 51 or greater genes 
(81455) provided July 29, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you are attaching the medical records and ask 
that the medical records be reviewed for medical necessity and the denial be overturned. The Plan denied your 
request. The Plan says clinical documentation was not submitted to substantiate medical necessity. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has Merkel cell carcinoma of left upper limb, including 
shoulder. In this case, the provider is requesting payment for the July 29, 2022, genetic testing although there is 
no clinical information documenting medical necessity. The review has determined that the items/services at 
issue in this case are not medically reasonable or 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the targeted genomic sequence analysis, 51 or greater genes (81455) provided July 29, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx (0239U) provided on August 
3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this service is not covered when provided OON and 
ordered by an OON provider without prior authorization. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the FoundationOne Liquid CDx (0239U) provided 
on August 3, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Supartz (CPT code J7321). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says that the step therapy criteria have 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 Plan did not forward the Schedule of Cost Sharing to support that the 
provider new about the step therapy process for the Plan. Therefore, we decided that the Plan has to pre-
approve Supartz (CPT code J7321).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulator (TENS) unit leads 
provided on August 3, 2022. 
 
You asked the Plan to pay for TENS supplies. You say that this claim was billed in accordance with policy. 
The Plan denied your request. The Plan says the enrollee confirmed that the billed item was not received. 
 
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 a valid proof of delivery. The delivery form does not include evidence of delivery 
of the specific items billed on this claim to the enrollee. 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 transcutaneous electrical nerve stimulator (TENS) unit leads provided on August 3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 51785 provided on October 13, 2021. 
 
You asked the Plan to pay for code 51785. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that this code was inappropriately coded. 
 
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. Review of the file shows that the Plan states that this code was inappropriately 
coded. The documentation did not include any information on why this code was inappropriately coded. In 
addition, the documentation did not include Medicare rules to support this denial. Therefore, the Plan did not 
substantiate their denial. Therefore, we decided that the Plan has to pay for code 51785 provided on October 
13, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for date of service May 11, 
2022. 
 
You asked the Plan to pay for procedure code 99239. You say that this service was medically necessary. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99239 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99239 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99239 billed for date of service May 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service October 8, 
2022 to November 4, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service October 8, 2022 to November 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941) provided on 
August 2, 2022 and August 12, 2022. 
 
You asked the Plan to pay for these services. You say that the chiropractic manipulative treatment provided 
was medically necessary. The Plan denied your request. The Plan says that you did not meet medical necessity 
criteria for coverage of the chiropractic services provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 these services. Our reviewer says that the 
services provided were not medically necessary. Our physician reviewer found that in this case, the record 
indicates that you have a lumbar subluxation. The record provided does not indicate that you are receiving 
active treatment but maintenance therapy as further clinical improvement cannot be reasonably expected from 
ongoing care. The elements of the coverage criteria are not satisfied. 
 
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 pay for the chiropractic manipulative treatments (98941) 
provided on August 2, 2022 and August 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood, occult, by fecal hemoglobin determination by 
immunoassay, qualitative, feces, 1-3 simultaneous determinations (82274) and colorectal cancer screening; 
fecal occult blood test, immunoassay, 1-3 simultaneous (G0328). 
 You asked the Plan to pay for the Cologuard colorectal cancer immunoassay screening. You say that you need 
this service because you are afraid to do a colonoscopy. The Plan denied your request. The Plan says this 
testing is not covered for enrollees who have symptoms. 
 
The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered every three years 
for enrollees who are asymptomatic.  
 
We looked at the file and Medicare rules. The medical records submitted show that you have a symptom of 
bleeding. Based on this information, we decided that Medicare rules for coverage of the Cologuard colorectal 
cancer immunoassay screening have not been met. Therefore, we decided that the Plan does not have to pay for 
blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous 
determinations (82274) and colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 
simultaneous (G0328).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 15, 2022, to 
February 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 15, 2022, to 
February 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 11, 2022, to 
May 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 11, 2022, to May 
10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee meets all indications for this 
procedure. The Plan denied your request. The Plan says this device should only be approved for patients 
enrolled in a clinical trial. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the optimized urinary tract infection (UTI) Panel + antibiotic 
resistance (ABR) panel (87798, 87500, 87801, 87150) provided on December 6, 2021. 
 
You asked the Plan to pay for the optimized UTI + ABR panel. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the requested testing exceeds the enrollee's medical 
needs. 
 
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 optimized UTI + ABR panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that per Infectious Disease Society of America and Healthcare Infection 
Control Practices Advisory Committee (HICPAC), state standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a urine culture and susceptibility studies. In addition, there is lack 
of support for the clinical utility of large multiplex polymerase chain reaction (PCR) urinary tract infection 
panel tests. The review has determined that the items/services at issue in this case were not medically 
reasonable or 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 optimized UTI + ABR panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the optimized urinary tract infection (UTI) Panel + antibiotic resistance 
(ABR) panel (87798, 87500, 87801, 87150) provided on December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) and a humidifier, heated, used with positive airway pressure device (E0562). 
 
You asked the Plan to pre-approve a CPAP device and humidifier. You say that you disagree with the denial. 
The Plan denied your request. The Plan says a CPAP device is covered when you have a diagnosis of 
obstructive sleep apnea (OSA) and have a sleep study that meets the apnea-hypopnea index (AHI) criteria. 
Your sleep study does not meet the requirements. 
 
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 a CPAP device and humidifier. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not support that you have an apnea-hypopnea 
index (AHI) or Respiratory Disturbance Index (RDI) that is greater than or equal to 15 events per hour with a 
minimum of 30 events, or an AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour 
with a minimum of 10 events and documentation of excessive daytime sleepiness, impaired cognition, mood 
disorders, or insomnia, or hypertension, ischemic heart disease, or a history of stroke. 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 CPAP device and humidifier have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device (E0601) and a 
humidifier, heated, used with positive airway pressure device (E0562).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with a tertiary gastroenterologist. 
 You asked the Plan to pre-approve the evaluation and management service. You say that you already have an 
appointment scheduled. You also say that you need this to be approved. The Plan denied your request. The Plan 
says the consultation can be provided in network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 evaluation and management service. 
Our reviewer says that the request to see a tertiary gastroenterologist is not medically necessary. Our physician 
reviewer found the provided documentation indicates that your medical circumstances do not make it necessary 
for a tertiary gastroenterology consult. The reviewer found that the Plan has in-network providers who meet the 
standards of care required for treatment of your condition. Therefore, the reviewer found that the request to see 
a tertiary gastroenterologist 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 evaluation and management service have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a consultation with a tertiary gastroenterologist.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
20, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. 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 for the HCPCS/CPT code will be denied. 
 
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. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
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 20, 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 given the enrollee's complex condition and risk of 
further medical complications, rehabilitation services cannot be safely or effectively provided at a lower level 
of care such as a skilled nursing facility. The Plan denied your request. The Plan says based on Medicare 
guidelines, the IRF services requested 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 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 acute IRF admission and services.