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

 
We decided that the Plan has to pre-approve a PET scan. 
 
You asked the Plan to pre-approve a PET scan. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that the requested study would exceed the allowed limit of three scans. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 a PET scan. Our reviewer says that a 
PET scan is medically reasonable and necessary. For recurrent metastatic cervical cancer, the NCCN 
Guidelines recommends a PET scan to restaging. You have biopsy proven recurrent disease and staging with a 
PET scan is necessary for determining treatment strategies base on extent of disease. Our physician reviewer 
found that your condition meets criteria for coverage of a PET scan. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a PET scan.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided 
from March 13, 2022, through March 14, 2022. 
 You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service was not medically necessary for 
the enrollee. 
 
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 pay for the SNF care. Our reviewer says that the 
skilled nursing facility care provided was not medically necessary. Our physician reviewer found that the 
enrollee did not require skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical 
matter the enrollee did not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 pay for the inpatient skilled nursing facility (SNF) care provided from March 13, 2022, through March 14, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for IRF admission and services. 
 
You asked the Plan to pay for IRF care. You say that the enrollee would benefit with intense therapy so they 
could go home quicker. The Plan denied your request. The Plan says the records do not show that the enrollee 
needs 3 hours of therapy 5 days per week. The enrollee's rehab needs are not complex, and they do not need to 
see a rehab doctor 3 times a week. The services the enrollee needs can be provided safely in other settings like 
a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 pay for IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or 
documented. At the current functional level, the enrollee does not need 3 hours a day 5 days a week of 
therapies. 
 
Documentation does not support the medical necessity due to lack of medical complexity and nursing needs 
and high functional level for admission to an IRF. While he would benefit from physical therapy and 
occupational therapy the enrollee's rehabilitation needs can be safely provided in an alternate and low intensity 
setting such as in a skilled nursing facility or in-home with therapies. 
 
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 pay for IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for DPYD (dihydropyrimidine dehydrogenase) gene analysis (81232) 
provided on December 1, 2021. 
 
You asked the Plan to pay for DPYD gene analysis. You say that this service was medically necessary and was 
billed appropriately. The Plan denied your request. The Plan says that 81232 was billed on one claim and 
several other gene codes were billed on another claim. Per Medicare billing rules, these services should be 
billed with a single panel code rather than several gene codes. 
 
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. Specifically, the Plan has not provided any information, such as the other claim, 
to show that this code was billed as part of a larger panel rather than the only test. Without this information, we 
cannot verify the Plan's denial due to incorrect billing. Therefore, we decided that the Plan has to pay for 
DPYD (dihydropyrimidine dehydrogenase) gene analysis (81232) provided on December 1, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing (96116, 96121, 96132, 
96133, 96136, 6137, 96138, 96139). 
 You asked the Plan to pre-approve neuropsychological testing. You say that the requested testing is necessary 
to document the enrollee's current neurocognitive function. The Plan denied your request. The Plan says the 
requested testing is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is intended to diagnose 
and characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. 
 
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 neuropsychological testing. Our 
reviewer says that the coverage criteria have not been met for the requested neuropsychological testing. Our 
physician reviewer found the provided documentation does not indicate that the enrollee is showing severity of 
symptoms that would warrant this type of diagnostic treatment. Therefore, the reviewer found that the 
requested testing is not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing (96116, 96121, 96132, 96133, 96136, 6137, 
96138, 96139).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 18, 2022 billed with 
codes 81240, 81241, and 81291. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
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 
February 18, 2022 billed with codes 81240, 81241, and 81291.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 22, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
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 lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis of 324 genes (0037U) 
provided on January 24, 2022. 
 
You asked the Plan to pay for the targeted genomic sequence analysis. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says genetic panels which include the FANCC gene are 
excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the FANCC is not a Medicare benefit 
and is a statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests 
that include the FANCC gene. 
 
We looked at the file and Medicare rules. The panel at issue included testing for the FANCC gene. Based on 
this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis have 
not been met. Therefore, we decided that the Plan does not have to pay for a targeted genomic sequence analysis of 324 genes 
(0037U) provided on January 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need more rides approved so you 
can go to your other appointments. The Plan denied your request. The Plan says 48 one-way trips is the benefit 
limit for your plan and cannot be extended once this benefit has been exhausted. 
 
  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 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that this request may have exhausted the Plan maximum benefit for coverage of routine transportation. The 
provided documentation shows that as of June 9, 2022, you have exhausted 37 of the allowed 48 trips. You had 
11 trips remaining as of June 9, 2022, and more than 48 trips are not covered by the Plan. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee feels that a skilled level of care 
is still needed. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of 
coverage were not met. 
 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 the SNF services. Our reviewer says 
that medical necessity cannot be established for continued SNF level of coverage. Our physician reviewer 
found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require 
skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the abdomen and pelvis 
(74176) provided on August 4, 2021. 
 
You asked the Plan to pay for the CT scan. You say that this service was billed appropriately and is supported 
in the medical record. The Plan denied your request. The Plan says the payment for this service is included in 
the inpatient payment for this enrollee which began on the same date. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that diagnostic services provided to a beneficiary by an admitting hospital within 3 days prior to and including the date of the beneficiarys admission are deemed to be inpatient services and are included in the 
inpatient payment. 
 
We looked at the file and Medicare rules. The record shows that the enrollee was admitted to the hospital on 
this same date. This means that the CT scan at issue is included as part of the inpatient payment. Based on this 
information, we decided that Medicare rules for separate payment of the CT scan have not been met. Therefore, 
we decided that the Plan does not have to pay for computed tomography (CT) of the abdomen and pelvis 
(74176) provided on August 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 24, 2021, 
through June 28, 2021 and billed with Diagnosis Related Group (DRG) 871. 
 You asked the Plan to pay for the inpatient hospital services billed with DRG 871. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the DRG billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 with primary diagnosis code A41.51. 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 inpatient hospital services billed with 
DRG 871. Our reviewer says that the documentation did not support DRG 871 with primary diagnosis code 
A41.51. Our physician reviewer found the enrollee was normotensive and not hypoxic, not thrombocytopenic, 
and had no alteration in mental status. Creatinine/total bilirubin were normal throughout the admission. Lack of 
systemic response to infection is indicative of a localized infection not progressing to sepsis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 24, 2021, through June 28, 2021 and billed with Diagnosis 
Related Group (DRG) 871.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF services which 
cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the records show 
that it is not reasonable to expect that the enrollee will be able to safely participate in, or fully benefit from, the 
intensity of services of an IRF. It is not reasonable to expect that the enrollee would be able to take part in 3 
hours of therapy 5 days a week or 15 hours of therapy a week. The enrollee's rehabilitation needs are not 
complex, and they do not need to see a rehabilitation doctor 3 times a week. The services the enrollee needs 
can be provided safely in other settings like a skilled nursing facility, home with home health services or home 
with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or 
documented. The enrollee does not need 3 hours a day or 5 days a week of therapies. 
 
Documentation does not support the medical necessity due to lack of medical complexity and nursing needs for 
admission to an IRF. While he would benefit from physical therapy and occupational therapy the enrollee's 
rehabilitation needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing 
facility. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for targeted genomic sequence analysis panel of 51 or greater genes 
(81455) provided on January 20, 2022. 
 
You asked the Plan to pay for targeted genomic sequence analysis panel. You say that this panel was medically 
necessary and reasonable for the management of the enrollee's advanced cancer. The Plan denied your request. 
The Plan says that the results of this panel are unlikely to impact the therapeutic decision-making in the clinical 
management of this enrollee, and therefore these services are not medically necessary in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for targeted genomic sequence analysis panel. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found that acute myeloid leukemia (AML) is a heterogeneous hematologic 
malignancy characterized by the clonal expansion of myeloid blasts in the peripheral blood, bone marrow, 
and/or other tissues. It is the most common form of acute leukemia among adults and accounts for the largest 
number of annual deaths from leukemias in the United States. Per the National Comprehensive Cancer 
Network (NCCN) Guidelines, molecular profiling should be considered if not done at diagnosis (including 
FLT3 mutations) as it may assist with selection of appropriate clinical trials and targeted treatments. There are 
promising ongoing clinical trials investigating targeted therapies based on molecular mutations for 
relapsed/refractory disease. In addition, molecular markers help with prognosis. Molecular profiling is 
considered a standard of care. Therefore, the services at issue were reasonable and 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 targeted genomic sequence analysis panel have been met. Therefore, we 
decided that the Plan has to pay for targeted genomic sequence analysis panel of 51 or greater genes (81455) 
provided on January 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist hand orthosis (L3908) provided on March 25, 2022. 
 
You asked the Plan to pay for a wrist hand orthosis. You say that this is supported in the records. The Plan 
denied your request. The Plan says a proof of delivery has not been submitted. 
 
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 for the supplies provided in this case. No delivery 
documentation was included in the submitted records. 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 a wrist hand orthosis (L3908) provided on March 25, 2022.