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

 
We decided that the Plan has to pay for ConfirmMDx testing (81551) provided on May 19, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
covered according to Medicare Local Coverage Determination L36327. The Plan denied your request. The Plan 
says that the LCD cited by the appellant does not apply to the Plan. The appropriate LCD, L35000, states that 
code 81551 is not covered by Medicare as services billed with this code are unlikely to impact therapeutic 
decision-making in the clinical management of an enrollee. 
 
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 based their denial of services on rules which do not apply 
in this case. When laboratory services are at issue, the LCD must apply to the state in which the laboratory is 
physically located. In this case, LCD L35000 does not apply to the state at issue; however, LCD L36327 does 
apply. Both this LCD and the Molecular Diagnostic Services (MolDX) Program list the test at issue as a 
covered service. Therefore, we decided that the Plan has to pay for ConfirmMDx testing (81551) provided on 
May 19, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept Procedure. 
 
You asked the Plan to pre-approve an Intracept Procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept Procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia injections (CPT code J0897). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has not been tried on either oral or self-administered drugs for 
osteoporosis; therefore, does not meet Centers for Medicare & Medicaid Services (CMS) LCD medical 
necessity guidelines for treatment with Prolia. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the record indicates that the enrollee has age related osteoporosis without osteoporotic fracture. The 
requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed 
the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to 
or would have an adverse effect from the Plan's preferred step one alternative. The elements of the coverage 
criteria are not satisfied. The requested service cannot be 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia injections (CPT code J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (CPT code 
64483). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 the service. Our physician reviewer 
found the enrollee has not met this requirement. The review has determined that the medical records provided 
do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging 
guidance (fluoroscopy or CT), lumbar or sacral, single level (CPT code 64483).
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 you feel that these should be covered as 
you have no other way to be transported to your appointments. The Plan denied your request. The Plan says 
you have exhausted the supplemental benefit for this service. 
 
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 60 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: Lab
Decision: Favorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing provided on March 
15, 2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the claim did not contain a Dex-Z code identifier. 
 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. Medicare rules say that Medicare nationally covers FDA-approved NGS testing, such as the F1CDx 
panel, when provided for an FDA-approved indication. 
 
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 uses Local Coverage Determination 
(LCD) L35025 and Local Coverage Article (LCA) A56853 to support their denial. However, the LCD and 
LCA provided are not valid for the provider's head quarter billing state of Pennsylvania. Therefore, we 
disregarded the LCD and LCA cited by the Plan. We cannot use LCD L35025 and LCA A56853 to substantiate 
our decision. We looked at the file and Medicare rules. This testing was provided to a patient with a solid 
tumor. The FDA approval notice indicates that this panel is approved for solid tumors. No other valid denial 
rationale was presented by the Plan. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne CDx (F1CDx) testing provided on March 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient care at the current hospital and can remain there until ready for discharge to a lower level of care such 
as an inpatient rehabilitation facility or even a skilled nursing facility. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytopathology provided on January 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for cytopathology. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 cytopathology provided on January 18, 2022, by 
an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia service (00901) provided on November 11, 
2021. 
 
You asked the Plan to pay for the anesthesia. You say that the service should be covered. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the anesthesia service (00901) provided on November 11, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MLH1 gene testing (81288) provided on October 13, 2021. 
 
You asked the Plan to pay for laboratory testing. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the documentation provided does 
not support the medical necessity of this test and to show how the results will impact the enrollee's treatment. 
 
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 laboratory testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation provide does not outline how the results of this test would impact the 
enrollee's treatment or disease 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 laboratory testing have not been met. Therefore, we decided that the Plan does 
not have to pay for MLH1 gene testing (81288) provided on October 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72192 billed for date of service December 
16, 2021. 
 
You asked the Plan to pay for procedure code 72192. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 72192 is bundled into 
payment for code 74176. 
 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 72192 
is a column II code to column I code 74176. 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 72192 billed for date of service December 16, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded as (81518) provided October 1, 
2021. 
 
You asked the Plan to pay for the genetic testing. You say that the treating provider ordered the Breast Cancer 
Index test is a safe and effective method to aid in evaluating cancer treatment options for the enrollee. The Plan 
denied your request. The Plan says tests not ordered by the physician who is treating the beneficiary are not 
reasonable and necessary. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Outreach was made to the referring provider indicated and the 
provider advised that they did not order the genetic testing. 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 genetic testing coded as (81518) provided October 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing coded as 0090U provided June 3, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that the myPath Melanoma test is a covered 
Medicare benefit under Local Coverage Decision MoIDX: myPath Melanoma Assay (L37879) and should be a 
covered benefit for the enrollee. The Plan denied your request. The Plan says these are non-covered services 
because this is deemed not medically necessary., 
 
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 0090U is Oncology (cutaneous melanoma), mRNA gene 
expression profiling by RT-PCR of 23 genes (14 content and 9 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a categorical result (ie, benign, indeterminate, malignant). 
 
We find that CPT code 0090U is not supported in the medical record. Specifically, the claim was billed with a 
date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on 
April 13, 2021, rather than the billed date of service June 3, 2021. Based on this information, we decided that 
Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory testing coded as 0090U provided June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve Freestyle Libre 14 Day CGM Sensor. You say that the enrollee has type 2 
diabetes mellitus and requesting coverage for a CGM sensor. The Plan denied your request. The Plan says the 
enrollee does not meet prior authorization criteria requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of Freestyle 
Libre 14 Day CGM Sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14 Day continuous glucose monitor (CGM) sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a hip fracture after a fall. The enrollee does not require treatment by multiple therapies, 
including either physical therapy (PT) or occupational therapy (OT), and an intensive rehabilitation therapy 
program. While the medical record supports a need for PT and/or OT, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that she will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hemodialysis consultation provided on February 26, 
2022, billed with code 90937. 
 
You asked the Plan to pay for the services as billed. You say that it is felt that the payment should be made as 
this code was correctly reported. The Plan denied your request. The Plan says the documentation supports code 
90935 for the rendered services. 
 
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 90937 is Hemodialysis procedure requiring repeated 
evaluation(s) with or without substantial revision of dialysis prescription. 
 
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 services as billed. Our reviewer says that the 
documentation does not support the use of code 90937. Our reviewer found the medical records submitted 
support a one-time evaluation for hemodialysis. The code is not supported as it requires repeated evaluation. 
There is a more appropriate code for the services provided.  
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 services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the hemodialysis consultation provided on February 26, 2022, billed with code 90937.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation, taxi (A0100). 
 
You asked the Plan to pre-approve additional trips. You say that the enrollee has 2 very important doctors 
appointments coming up and you have no other way there. The Plan denied your request. The Plan says this 
request exceeds the Plan's benefit limitation. 
 
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 one-way trips to Plan approved locations every year 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 non-emergency transportation, taxi (A0100).