Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post-stabilization services provided from November 2, 
2021, to November 8, 2021. 
 
You asked the Plan to pay for the post-stabilization services. You say that prior authorization could not have 
been obtained. You also say that you would like authorization approved on the basis of medical necessity. The 
Plan denied your request. The Plan says the treating provider is non-contracted with the Plan, and prior 
authorization was not obtained as required by the Plan. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization services. Our reviewer 
says that the post-stabilization services without authorization were not reasonable and necessary. Our physician 
reviewer found the provided care was neither emergent nor urgent. The enrollee underwent elective surgery 
without immediate complications. Our reviewer found that pre-authorization for the out-of-network 
hospitalization should have been sought. Our physician reviewer also found that subsequent authorization for 
post-stabilization care should have been sought. 
 
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 post-stabilization services have not been met. Therefore, we decided that the 
Plan does not have to pay for the post-stabilization services provided from November 2, 2021, to November 8, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is appropriate for skilled nursing facility 
care. The Plan denied your request. The Plan says we did not approve this request because the information 
provided does not show the enrollee needs daily skilled nursing or skilled therapy services. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our 
reviewer also found that the enrollee does not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of eczematous or infected skin (11000) 
billed on September 21, 2021. 
 
You asked the Plan to pay for the debridement of eczematous or infected skin (11000). You say that you are 
able to bill for these services separately and the provider should be paid for the act of debridement. The Plan 
denied your request. The Plan says procedure code 11000 is not supported by the medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 11000 is debridement of extensive eczematous or 
infected skin; up to 10% of body surface. 
  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 debridement of eczematous or infected skin (11000). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that there is insufficient documentation to confirm extensive debridement up to 10% of body 
surface. In this case wound care is documented, but CPT code 11000 is not supported. 
 
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 debridement of eczematous or infected skin (11000) have not been met. 
Therefore, we decided that the Plan does not have to pay for the debridement of eczematous or infected skin 
(11000) billed on September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81001 billed for date of service October 20, 
2021. 
 
You asked the Plan to pay for procedure code 81001. You say that the documentation supports the claim. The 
Plan denied your request. The Plan says an appropriate modifier was not 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, we have confirmed that code 81001 is a column II code to column I code G0483. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81001 
billed for date of service October 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary at this time as it 
would not be clinically advantageous. Completion of treatment at the current facility. is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 7, 2022 billed with 
codes 81407, 81406, 81405, 81404, and 81403. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 
April 7, 2022 billed with codes 81407, 81406, 81405, 81404, and 81403.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 15, 2022 billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, and 81294. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 
April 15, 2022 billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, and 81294.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 20, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly.  
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A57526. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on April 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services provided to the enrollee on September 
2, 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 services are included in the hospital's contract rate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A0425, A0428 is not supported in the medical record. Specifically, as the enrollee was 
inpatient at this time, the services cannot be reported separately. 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 transportation services provided to the enrollee on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) 
provided January 8, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the Plan's coverage 
determination and requesting full payment for Guardant360 CDx at the national Medicare rate of $5,000. The 
Plan denied your request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 0242U is targeted genomic sequence analysis panel, solid 
organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene 
copy number amplifications, and gene rearrangements. 
 
We find that CPT code 0242U is not supported in the medical record. Specifically, the claim did not include all the documentation to process the claim. The required DEX Z-Code was not provided. Additionally, the claim 
was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen 
was collected on January 3, 2022, rather than the billed date of service January 8, 2022. There is no 
documentation to support genetic testing on the billed date of service. Based on this information, we decided 
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) provided January 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from January 31, 2022, to 
February 2, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says service from 
non-participating providers are not covered under an HMO plan unless preauthorized. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided from January 31, 2022, to  
February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint. You say that the 
requested radiofrequency ablation (RFA) to the sacroiliac (SI) joint is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for the requested radiofrequency ablation (RFA) 
to the sacroiliac (SI) joint. 
 
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 radiofrequency ablation (RFA) to the 
sacroiliac (SI) joint. Our reviewer says that the enrollee does not meet criteria for the requested radiofrequency 
ablation (RFA) to the sacroiliac (SI) joint. Our physician reviewer found according to the literature, sacral 
lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint 
mediated pain is considered experimental and investigational.  Radiofrequency ablation for denervation, 
whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and 
therefore, not medically necessary. The review has determined that the 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 radiofrequency ablation (RFA) to the sacroiliac (SI) joint have not been met. 
Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the 
sacroiliac (SI) joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot rendered on June 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that claim lines billed with codes without a KX, GA or GZ 
modifier will be rejected as missing information.  
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required KX, 
GA, or GZ modifier. Therefore, we decided that the Plan does not have to pay for the walking boot rendered on 
June 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that the enrollee has been on this medication for 3 years. 
The Plan denied your request. The Plan says Dupixent is a self-administered drug and does not fall under Part 
B coverage. The Plan says that the enrollee has TRS-CARE MA which provides its own pharmacy benefits. 
The Plan says that the enrollee's prescription coverage is provided through CVS Silverscript. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.  
 Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
provided on February 10, 2022. 
 
You asked the Plan to pay for the CPAP device. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the item rendered is not supported by the documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the medical records submitted do not include sufficient detail to 
support the service as billed. The documentation does not include the itemized shipping/billing invoice to 
indicate the specific supplies and proof of delivery for continuous positive airway pressure (CPAP) device; 
therefore, this item cannot be supported. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
continuous positive airway pressure (CPAP) device provided on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 11, 2021 billed with 
codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194 and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that based on the information, you request 
reconsideration of this determination and coverage of the Tempus Gene Panel test at the in-network benefit 
level. The Plan denied your request. The Plan says claim does not meet Medicare NCD/LCD criteria. 
 
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. Additionally, the claim was billed with a date of service inconsistent with Medicare rules 
governing laboratory services. The specimen was collected on June 23, 2021 rather than the billed date of 
service August 11, 2021. 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 August 11, 2021 billed with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 
81298, 81301, 81317, 81401, 81194 and 81309.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT) (two 
fractions) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the additional information available, the request does not meet the Medicare or 
health plan coverage criteria. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee appears to have multiple sites of metastases as evidenced from positron emission 
tomography/computed tomography (PET/CT) and magnetic resonance imaging (MRI), with two sites of 
growing metastases. It is unclear if these are from breast cancer or multiple myeloma. In addition a bone 
marrow biopsy from the left iliac crest on 11/7/19 revealed breast cancer, suggesting widespread involvement 
of disease. There are also likely multiple additional lesions present as the MRI scan was limited to the sacrum, and showed multiple lesions. This is therefore not oligometastatic disease. Even if one were to advocate this 
being oligometastatic disease, results from NRG BR002 (presented as ASCO) do not support routine use of 
SBRT for oligometastases from breast cancer. It is reasonable to offer this patient palliative radiotherapy, 
perhaps with techniques and doses in excess standard 2D palliative regimens, but there is not an evidenced 
based rationale for SBRT in this patient. Routine use of SBRT for oligoprogressive breast cancer or multiple 
myeloma is not an accepted standard 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve stereotactic body radiation therapy (SBRT) (two fractions) for the enrollee.