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

 
We decided that the Plan does not have to pay for the genetic testing provided on January 7, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the genetic testing provided included 
testing for the FANCC gene. 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 provided on January 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81288, 81295, 81298, 81317, 81321, 81323) 
provided October 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one CPT code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81288, 81295, 81298, 81317, 81321, 
81323) provided October 3, 2021.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and your needs can be met at an alternate level 
of care such as in a skilled nursing facility. 
 
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 while you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program such as 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on January 11, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that you would like to appeal the denial 
of the claim. 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 hospital outpatient clinic visit provided on January 
11, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of heart without contrast 
material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT of heart without contrast material, with quantitative evaluation of 
coronary calcium. You say that the requested service is medically necessary. The Plan denied your request. The 
Plan says the service at issue is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT of heart without contrast material, 
with quantitative evaluation of coronary calcium. Our reviewer says that the requested service is not medically 
necessary. Our physician reviewer found based on current lipid values and past medical history you would 
already be appropriate for a statin and there was no report of refusal or other specific issues that would require 
risk stratifying via CT calcium scoring. 
 
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 CT of heart without contrast material, with quantitative evaluation of coronary 
calcium have not been met. Therefore, we decided that the Plan does not have to pre-approve computed 
tomography (CT) of heart without contrast material, with quantitative evaluation of coronary calcium (75571).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous nerve ablation procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed 
conservative treatment. The Plan denied your request. The Plan says it is considered experimental and 
investigational. 
 
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 requested services. Our physician 
reviewer found that the Intracept procedure experimental. More research is needed to show safety and efficacy. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous nerve ablation procedure.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services provided on December 22, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that the provider was not eligible for 
payment on the date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. The plan has not verified why the 
provider in this case is unable to provide anesthesia services. Therefore, we decided that the Plan has to pay for 
the anesthesia services provided on December 22, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 22, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from August 
13, 2021, to October 11, 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 RAP claim was received on November 22, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
A valid RAP was not filed within the appropriate period of time. 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 home health services provided to the enrollee from August 13, 2021, to October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Apple Smart Phone purchased on November 5, 2021. 
 
You asked the Plan to pay for an Apple Smart Phone. You say that this item was necessary for your other 
equipment to function. The Plan denied your request. The Plan says this equipment is not covered by Medicare 
or by the Plan's supplemental benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The Plans contract also says that they provide supplemental coverage for equipment beyond 
that Medicare covers. Smart phones are not among those covered under this benefit. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. The item is also 
not covered under the Plans supplemental benefit. Therefore, we decided that the Plan does not have to pay for an Apple Smart Phone purchased on November 5, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical collar (L0180) provided on July 20, 2021. 
 
You asked the Plan to pay for a cervical collar. You say that the item at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
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. 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 cervical collar (L0180) provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99212), a skin biopsy (11102, 
11103), and a destruction of premalignant lesions (17000) provided on January 13, 2022, by a provider who 
has opted out of the Medicare program. 
 
You asked the Plan to pay for a physician office visit, a skin biopsy, and a destruction of premalignant lesions. 
You say that you should be reimbursed for whatever costs are covered by the Plan. The Plan denied your 
request. The Plan says rules for payment have not been met because the provider at issue has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a physician office visit (99212), a skin biopsy (11102, 11103), and a destruction of premalignant lesions (17000) 
provided on January 13, 2022, by a provider who has opted out of the Medicare program.
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 LTACH care is medically reasonable 
and necessary. 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 the patient is a 56-year-old male who was admitted to an acute care hospital with 
cellulitis of the right leg of post-operative wound. In this case, the patient appears to be stable and improving, 
and they should only require short-term additional acute care services that can be safely completed at the 
current facility until appropriate for a lower level of care. The patient does not require services at the LTACH 
that are not already available at the current facility. Transfer to the LTACH is not medically necessary 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for continuous glucose monitor (CGM) supplies provided on December 28, 
2021. 
 
You asked the Plan to pay for the CGM supplies. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says that medical records are needed to determine coverage. 
 
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's sole initial denial rationale was that no medical records 
were provided to support necessity of the CGM supplies.  However, with your appeal request, you submitted 
full medical records.  It does not appear that the Plan has made any attempt to review these records.  It does not 
appear that the Plan has made any determination regarding these medical records.  You have complied with the 
Plan's request for medical records, and they have failed to act on them. The burden is on the Plan to show why 
its denial is appropriate.  Since the Plan's only reason for denial was lack of records, and those records were 
provided, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for 
continuous glucose monitor (CGM) supplies provided on December 28, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on November 30, 
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 denied code 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 15734 is "Muscle, myocutaneous, or fasciocutaneous 
flap; trunk." 
 
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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the record indicates that the enrollee 
underwent a procedure. The record indicates that an omental pedicle flap was created. The record provided 
does not indicate that a muscle, myocutaneous, or fasciocutaneous flap was performed. The elements of the 
coverage criteria are not satisfied. 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 have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect testing provided on December 9, 2021. 
 
You asked the Plan to pay for the CxBladder Detect testing. You say that this testing should be covered per 
Medicare rules. The Plan denied your request. The Plan says this is not a Medicare-covered test. 
 
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 CxBladder Detect testing. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found CxBladder is not considered a screening test for urothelial cancer. Cystoscopy, 
ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results in patients 
with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and 
low-grade tumors.   
 
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 CxBladder Detect testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the CxBladder Detect testing provided on December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bathroom safety bars, purchased on December 3, 2021. 
 
You asked the Plan to pay for the bathroom safety bars. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the bathroom safety bars, purchased on December 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consumer-directed personal assistance services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there are no medical records identified for review. As such, you have no documented skilled nursing 
needs or documented skilled therapy needs. As such, these services in the home are not reasonable or 
necessary. In general, custodial care services are not covered. 
 
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 consumer-directed personal assistance 
services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the Superion device. 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 pre-approve the Superion device. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Superion device is experimental. More research is needed to show safety and efficacy 
of this device. 
 
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 Superion device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Superion interspinous spacer device.