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

 
We decided that the Plan does not have to pre-approve a minimally invasive tissue excision with a possible 
redundant skin excision (14302, 15839, 15878). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has solid-predominant lymphedema of the upper 
extremity. The record is insufficient to support the medical necessity of the requested service at this time.  
  
 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a minimally invasive tissue excision with a possible redundant skin excision (14302, 
15839, 15878).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 3, 2023. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the diagnosis code at issue is not appropriate 
as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code F05, described as 
delirium due to known physiological condition. This code is not an appropriate primary diagnosis as the code 
has a code first note indicating to code the underlying condition first. Based on this information, we decided 
that Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on May 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on May 22, 2023, billed with code 
0241U. 
 
You asked the Plan to pay for the lab testing as billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says the medical records do not support the billing of code 0241U. 
 
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 0241U is infectious disease (viral respiratory tract 
infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], 
influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen 
reported as detected or not detected. 
 
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 lab testing as billed. Our reviewer says that the records 
do not support the code 0241U.  Our reviewer found code 0241U is a Proprietary Laboratory Analyses (PLA) 
code, meaning that the code applies to only one unique lab test made by a specific manufacturer or performed 
by a specific lab. There is a more specific code to report for documented service in this case. 
 
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 lab testing as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab testing provided on May 22, 2023, billed with code 0241U.
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 this would help the enrollee return home to maintain 
their independence and quality of life. The Plan denied your request. The Plan says the services do not meet the 
requirements for approval. 
 
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 does not need physician supervision three times a week in the IRF. 
There is no medical complexity or acute rehab nursing needs documented. The enrollee does not need intensive 
therapies consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach in an IRF. The complexity of the enrollees medical, rehab, and nursing needs (combined complexity) 
was not appropriate for acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative 
care. The enrollees rehab 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled nursing visits beyond what have already been approved. Records 
document the enrollee has been educated on his disease process and medications. Records do not document the 
need for intravenous medications, new tube feeding or ostomy care or complex wound 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88108) provided on March 29, 2023. 
 
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 this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 23, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (88108) provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment, includes placement 
(D6057) for teeth numbers 5 and 6, abutment supported porcelain/ceramic crown (D6058) for teeth numbers 5 
and 6, and pontic, porcelain/ceramic (D6245) for tooth number 3. 
 
You asked the Plan to pre-approve a custom fabricated abutment, includes placement (D6057) for teeth 
numbers 5 and 6, abutment supported porcelain/ceramic crown (D6058) for teeth numbers 5 and 6, and pontic, 
porcelain/ceramic (D6245) for tooth number 3. You say that these implants are needed in order to be able to 
chew food properly. The Plan denied your request. The Plan says the dentist's notes/x-rays do not show it is 
needed for a procedure to place, remove or treat an implant.  
 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. The Plan covers a custom 
fabricated abutment, includes placement (D6057) for teeth numbers 5 and 6, abutment supported 
porcelain/ceramic crown (D6058) for teeth numbers 5 and 6, and pontic, porcelain/ceramic (D6245) for tooth 
number 3 when the services are medically necessary and reasonable.  
 
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 custom fabricated abutment, includes 
placement (D6057) for teeth numbers 5 and 6, abutment supported porcelain/ceramic crown (D6058) for teeth 
numbers 5 and 6, and pontic, porcelain/ceramic (D6245) for tooth number 3. Our reviewer says that the service 
is not medically necessary. Our physician reviewer found in order to place custom fabricated abutments; the 
implant bodies must be present. Our physician reviewer also found that a more specific treatment plan must be 
submitted indicating where the placement of the implant bodies are planned to replace the missing teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a custom fabricated abutment, includes placement (D6057) for teeth numbers 5 
and 6, abutment supported porcelain/ceramic crown (D6058) for teeth numbers 5 and 6, and pontic, 
porcelain/ceramic (D6245) for tooth number 3 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom fabricated abutment, includes placement (D6057) for teeth numbers 5 and 6, 
abutment supported porcelain/ceramic crown (D6058) for teeth numbers 5 and 6, and pontic, porcelain/ceramic 
(D6245) for tooth number 3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing coded as 81240 provided April 20, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that please reconsider this claim for payment based 
on medical necessity. The Plan denied your request. The Plan says genetic testing procedures submitted under 
CPT code 81240 are non-covered by Medicare. 
 
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. 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 
genetic testing coded as 81240 provided April 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
May 8, 2023, and billed with codes 87481, 87500, 87640, 87652, 87798, 87799, and 87900. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on May 8, 2023, and billed with codes 87481, 87500, 87640, 87652, 87798, 87799, and 87900.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G (L8702). 
 
You asked the Plan to pre-approve the MyoPro brace. You say that the enrollee was referred by their doctor for 
myoelectric restoration using the MyoPro Motion G. The Plan denied your request. The Plan says this item is 
considered experimental and investigational. There is insufficient evidence of its safety and effectiveness. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the MyoPro brace have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound cover (A6196) and foam dressing (A6212) 
provided on May 24, 2023. 
 
You asked the Plan to pay for the wound cover (A6196) and foam dressing (A6212). You say that the items 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the wound cover 
(A6196) and foam dressing (A6212) provided on May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
June 19, 2023, and billed with codes 87481, 87640, 87652, 87798, and 87799. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on June 19, 2023, and billed with codes 87481, 87640, 87652, 87798, and 87799.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81270, 81279, 81338, 88184 
and 88185 provided May 8, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing on the denial for the 
Plan's refusal to pay the claim for laboratory services. What recourse do you have when the doctor does not 
cooperate. The Plan denied your request. The Plan says the authorization requested for this service as not 
approved. Under Medicare guidelines, this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Additional records were required to support medical necessity of the services. The records show that the Plan 
made multiple attempts to obtain the needed records from the provider without success. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded as 81270, 81279, 81338, 88184 and 88185 
provided May 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care provided on November 3, 
2022, by a non-network provider. 
 
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 rendered by a non-network provider without prior authorization. 
 
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 the initial nursing facility care provided on 
November 3, 2022, by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on December 11, 
2022. 
 
You asked the Plan to pay for the Tempus xF testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this test has not had FDA approval or clearance as a companion in 
vitro diagnostic or an FDA-approved or cleared indication for use in this enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Tempus xF testing (81455) provided on December 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport (A0425) provided on December 23, 
2022. 
 You asked the Plan to pay for the ambulance transport. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the ambulance transportation is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by 
ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic 
services not available at the facility where the patient is an inpatient is covered under the inpatient payment and 
is not separately payable. 
 
We looked at the file and Medicare rules. The enrollee was an inpatient at the time this transportation was 
provided. Based on this information, we decided that Medicare rules for coverage of the ambulance transport 
have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transport (A0425) 
provided on December 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0667, E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that the enrollee 
needs the compression boot flex touch plus system to help with leg swelling. The Plan denied your request. The 
Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed 
four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0667, E0656).