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

 
We decided that the Plan does not have to pay for the PrismRA testing provided on April 14, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the PrismRA test identifies rheumatoid arthritis (RA) patients who are unlikely to respond to anti-
tumor necrosis factor (anti-TNF) therapies. Medicare guidelines say that this type of service is covered under 
certain conditions: The diagnostic laboratory test using NGS must have: Food & Drug Administration (FDA) 
approval or clearance as a companion in vitro diagnostic; and, an FDA-approved or -cleared indication for use in that patients cancer. Under Medicare guidelines, the request is not medically necessary because the 
requested test is not FDA approved. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the PrismRA testing provided on April 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of breast localization device(s) (19281) 
provided December 22, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that you disagree with this denial and request that 
this decision be reversed. The Plan denied your request. The Plan says device code required with dependent 
procedure. 
 
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 19281 is placement of breast localization device(s) (eg, 
clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic 
guidance. 
 
We find that CPT code 19281 is not supported in the medical record. Specifically, per Medicare guidelines 
HCPCS/CPT code 19281 is identified in Addendum B by status indicator Q1 which is defined as a Q1-
packaged service. OCE edit identified the packaged service HCPCS/CPT code 19281 as a device intensive 
procedure that was reported without a device HCPCS code required for that procedure and under the OPPS 
separate payment is made for packaged services when no status indicator-Q1 services have been reported on 
the same claim. Based on this information, we decided that Medicare rules for coverage of the diagnostic 
service have not been met. Therefore, we decided that the Plan does not have to pay for the placement of breast 
localization device(s) (19281) provided December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 24, 2022. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was 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. The testing was billed with multiple codes on multiple claims. 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 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for the enrollee. 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered 
because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve 
a power seat elevation feature (E2300) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of continuous positive airway pressure 
(CPAP) device (E0601). 
 You asked the Plan to pre-approve the CPAP replacement. You say that you feel that the CPAP should be 
covered because you cannot sleep without the CPAP. The Plan denied your request. The Plan says that records 
were not provided that supports 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 pre-approve the CPAP replacement. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation from the treating 
provider that the enrollee's sleep apnea symptoms are improved with use of the CPAP device and records do 
not document objective evidence of adherence to use of the CPAP device with review by the treating provider. 
 
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 CPAP replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve replacement of continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798, and 87641 
billed for date of service October 22, 2021. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87653, 87798, and 87641. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says payment 
for codes 87150, 87481, 87653, 87798, and 87641 is bundled into payment for other codes. 
 
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 87150 
is a column II code to column I code 87500. We have confirmed that codes 87481, 87653, 87798, and 87641 
are column II codes to column I codes 87801 and 87150. These claims have not been billed with an appropriate 
modifier to bypass the edit. Based on the claims submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798, and 
87641 billed for date of service October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640, 87641, 87653, 87661, and 87798 
billed for date of service February 23, 2022. 
 
You asked the Plan to pay for procedure codes 87640, 87641, 87653, 87661, and 87798. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says payment 
for codes 87640, 87641, 87653, 87661, and 87798 are bundled into payment for code 87150. 
 
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 codes 
87640, 87641, 87653, 87661, and 87798 are column II codes to column I code 87150. 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 codes 87640, 87641, 
87653, 87661, and 87798 billed for date of service February 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, 
including programming (CPT code 33285). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an 
implantable loop recorder (ILR). In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ILR in this enrollee's clinical management. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, including programming (CPT code 
33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid testing 
provided on March 31, 2021. 
 
You asked the Plan to pay for the lab testing provided. You say that this is medically necessary testing that 
should be covered. The Plan denied your request. The Plan says many of the codes billed were Column 2 codes 
reported without an appropriate modifier. In addition, the two Column 1 codes on the claim were not 
specifically noted in the order form. As such, none of the billed tests can be considered supported. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory testing must be ordered by a treating 
provider to be covered.   
 
We looked at the file and Medicare rules. The order form only indicates that bacteria and yeast urinary tract 
infection (UTI) be performed, along with "resistant genes". There is not sufficient specificity in this order to 
support that the provider intended these specific tests to be rendered. No progressive notes from the ordering 
physician were submitted. Based on this information, we decided that Medicare rules for coverage of the lab testing provided have not been met. Therefore, we decided that the Plan does not have to pay for the infectious 
agent detection by nucleic acid testing provided on March 31, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing (0037U) provided on 
February 15, 2022. 
 
You asked the Plan to pay for the FoundationOne CDx (F1CDx) testing. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication.  
 
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. Based on this information, we decided that Medicare rules for coverage of F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing (0037U) provided on February 15, 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: 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 these services are medically necessary. 
The Plan denied your request. The Plan says that you are not stable enough for transfer to this lower level of 
care and your needs appear more appropriate for the acute care hospital where you are currently. 
 
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. You appear 
to still be somewhat unstable and require short-term additional acute care services that can be safely 
administered at the current facility until you are more stable and/or more appropriate for a lower level of care. 
You do not require services at the LTACH that are not already available at the current facility. Our physician 
reviewer found that your condition does not meet Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3330 and D3320) provided by an out-
of-network provider on April 19, 2022. 
 
You asked the Plan to pay for endodontic therapy. You say that you were never told that this provider was out-
of-network. The Plan denied your request. The Plan says the rendered dental work is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
endodontic therapy (D3330 and D3320) provided by an out-of-network provider on April 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arm sling. 
 
You asked the Plan to pre-approve the requested sling. You say that your doctor told you that you should use a 
sling at all times while you heal, or the effects of the surgery could be reversed. The Plan denied your request. 
The Plan says there is no written order from your doctor for the requested sling and attempts to receive medical 
records have been unsuccessful. 
 
The Plan must follow Medicare rules. Medicare rules say that certain braces may be covered by Medicare when 
ordered by a physician. Such devices must be rigid or semi-rigid in order to qualify for coverage. 
 
We looked at the file and Medicare rules. The documentation does not show that a brace was ordered by your 
treating physician. In addition, the requested type of sling is not at least semi-rigid, meaning that it does not 
qualify for coverage under Medicare. Based on this information, we decided that Medicare rules for coverage 
of the requested sling have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
arm sling.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 21, 2021, and 
billed with codes 81325, 81404, 81406, 81407, 81408, and 81479. 
 
You asked the Plan to pay for genetic testing. You say that this is a covered service. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 21, 2021, and billed with codes 81325, 81404, 81406, 81407, 81408, and 81479.
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 you need LTACH services. The Plan 
denied your request. The Plan says rules for LTACH care have 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 that you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are 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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve eleven (11) 3D radiation therapy treatments (CPT code(s): 77263, 
77427, 77336, and 77300). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the enrollee's doctor has asked for 33 treatments. The Plan states this number of 
treatments cannot be approved as they are not medically necessary. 
 
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 pre-approve the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the treatment would be within accepted standards of medical practice. The LCD provided on 
proton therapy does not apply and the standard medical necessity criteria are met. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve eleven (11) 3D radiation therapy treatments (CPT code(s): 77263, 77427, 77336, and 77300).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne testing (0037U) provided on March 23, 
2022. 
 
You asked the Plan to pay for FoundationOne testing. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed with the correct date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that as a general rule, the date of service for a clinical 
laboratory test must be the date the specimen was collected.  
 
We looked at the file and Medicare rules. The testing at issue was billed with a date of service of March 23, 
2022, but the record shows that the specimen was collected on February 22, 2022. Based on this information, 
we decided that Medicare rules for coverage of FoundationOne testing have not been met. Therefore, we 
decided that the Plan does not have to pay for FoundationOne testing (0037U) provided on March 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on April 05, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for Medicare-covered one-way ground ambulance benefit. Covered ambulance services include 
fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide 
care if they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. 
 
You have been asked to pay a $150 copayment for ambulance. Ambulance falls within the Ambulance Services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance on April 05, 2022.