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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited reconsideration for 
the denial of a SNF admission. The Plan denied your request. The Plan says the enrollee's status does not meet 
severity or intensity medical necessity criteria for a skilled nursing level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee requires endurance and strength training which do not require daily skilled 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 16, 2022, to 
February 1, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.00, described as acute 
respiratory failure, unspecified whether with hypoxia or hypercapnia. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that documentation does not support the billed code. Our physician reviewer found there is no evidence that the 
enrollee had respiratory failure.  As such, the billing of J96.00 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 16, 2022, to February 1, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Wats3D analysis provided on May 27, 2022. 
 
You asked the Plan to pay for the Wats3D analysis. You say that the Wats3D analysis provided on May 27, 
2022, was medically necessary. The Plan denied your request. The Plan says the Wats3D analysis provided on 
May 27, 2022, was 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 Wats3D analysis. Our reviewer says that 
the Wats3D analysis provided on May 27, 2022, was not medically necessary. Our physician reviewer found the American Society of Gastrointestinal Endoscopy suggests using WATS-3D (brush) biopsy testing in 
patients with known or suspected Barrett's esophagus. The clinical documentation does not support that the 
enrollee in this case had known or suspected Barrett's esophagus. 
 
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 Wats3D analysis have not been met. Therefore, we decided that the Plan 
does not have to pay for the Wats3D analysis provided on May 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test provided on September 30, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that the DecisionDx-SCC test was medically 
necessary. The Plan denied your request. The Plan says the DecisionDx-SCC test is 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 pay for the DecisionDx-SCC test. Our reviewer says 
that the requested DecisionDx-SCC test is not considered medically reasonable and necessary. Our physician 
reviewer found that the Dx-SCC test is an empirically derived multi-analyte algorithmic assay. The test analyzes formalin fixed primary tumor tissue to classify patients as low (Class 1), moderate (Class 2A) or high 
(Class 2B) biological risk of metastasis. The literature indicates that Decision Dx-SCC is considered not 
medically necessary because of a lack of peer reviewed published literature supporting the test's utility. The 
review has determined that the DecisionDx-SCC test at issue in this case is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DecisionDx-SCC test have not been met. Therefore, we decided that the 
Plan does not have to pay for the DecisionDx-SCC test provided on September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 87636 for January 
27, 2023. 
 
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 claim for this molecular pathology testing did not include the required unique 
identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with 
code 87636 for January 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy provided on December 5, 2022. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid 
biopsy have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF liquid 
biopsy provided on December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Aortopathy comprehensive panel (81411, 81410) 
provided December 15, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the enrollee's physician ordered genetic testing 
for the enrollee due to its validated clinical utility in clarifying disease risk. The Plan denied your request. The 
Plan says per DEX Diagnostics, this test is not 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. CPT codes 81410 and 81411 are listed under Group 3 paragraph, Tier 
1 Non-covered codes. 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 Invitae Aortopathy 
comprehensive panel (81411, 81410) provided December 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Nerve Trio nerve stimulator rendered on January 6, 
2023. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that where electric nerve stimulation is employed to treat 
motor function disorders, no reimbursement may be made for the stimulator or for the services related to its 
implantation. 
 
We looked at the file and Medicare rules. The file shows that the services were performed to treat essential 
tremor. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the Cala Nerve Trio nerve stimulator 
rendered on January 6, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to make separate payment for the imaging services provided on 
December 13, 2022, billed with code 73630. 
 
You asked the Plan to make separate payment for the imaging services as billed. You say that this should be 
reimbursed as billed. The Plan denied your request. The Plan says no Medicare payment can be made for this 
code when billed with code 99283. 
  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 73630 has a status indicator of Q1 in the Outpatient Prospective Payment System (OPPS). This means 
that payment is packaged when billed with a code with status indicator S, T, or V. Code 99283 was billed on 
the same claim, and this code has an indicator of V. Based on this information, we decided that Medicare rules 
for coverage of the imaging services as billed have not been met. Therefore, we decided that the Plan does not 
have to make separate payment for the imaging services provided on December 13, 2022, billed with code 
73630.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bevacizumab injection (codes 67028 and J9035) billed 
for date of service November 3, 2022. 
 
You asked the Plan to pay for codes 67028 and J9035. You say that these services were medically necessary. 
The Plan denied your request. The Plan says you did not bill for this injection properly because different codes 
are used for ophthalmologic uses of Bevacizumab. 
 
The Plan must follow Medicare rules. Medicare rules say that when billing for bevacizumab injections for 
ophthalmological purposes, it is not appropriate to use code J9035. Either code J7999 or C9257 should be used 
to bill for bevacizumab for intravitreal injections. 
 Records show that the provider provided bevacizumab via an intravitreal injection for ophthalmological 
purposes with code J9035.  This is not the appropriate code to use for this indication.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 67028 and J9035 have not been met. Therefore, we decided that the Plan does not have to 
pay for the bevacizumab injection (codes 67028 and J9035) billed for date of service November 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that the device 
is medically necessary for bilateral use. The Plan denied your request. The Plan says the records do not show 
that you have any truncal edema and you have not had 4 weeks of regular, daily, multiple-hour home usage of 
the E0650 or E0651. In addition, your leg swelling improved with conservative treatment. You do not meet 
criteria for approval. 
 
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 a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99213) provided on April 4, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that you are being billed for an office visit. You 
say that this was denied as being part of another procedure. You also say that you only had an office 
evaluation. The Plan denied your request. The Plan says that there was a problem with the way the provider 
billed this claim. 
 
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 file does not support that the service in this case was performed 
with another service. In addition, the Plan's records do not show that you have any liability. Therefore, we 
decided that the Plan has to pay for the office visit (99213) provided on April 4, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group psychotherapy (procedure code 90853) billed for date 
of service December 6, 2022, to December 28, 2022. 
 You asked the Plan to pay for procedure code 90853. You say that this service not not performed multiple 
times on each day. These services were medically necessary to your recovery and treatment. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 90853 is 1. The MAI value for this code is 3. The provider of these 
services billed 8 units of this code per day, exceeding the MUE. In your appeal, you confirmed that you only 
received one unit of this service per day.  It appears as though your provider is billing incorrectly.  You have 
the right to ask your provider to correct the bill to indicate the true number of units received. However, the Plan 
cannot be required to pay for these additional units. Based on this information, we decided that Medicare rules 
for coverage of procedure code 90853 have not been met. Therefore, we decided that the Plan does not have to 
pay for group psychotherapy (procedure code 90853) billed for date of service December 6, 2022, to December 
28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial foot, molded socket, tibial tubercle height, with 
toe filler (L5020). 
 
You asked the Plan to pre-approve a partial foot, molded socket. You say that the enrollee requires a new lower 
LEFT limb prosthesis due to the poor fit of current prosthesis. Patient is experiencing pain, bruising, and 
ambulation difficulties with his current prosthesis despite numerous adjustments. The Plan denied your request. 
The Plan says the request for this component is not reasonable or necessary per Medicare guidelines. A partial 
foot prothesis does not meet enrollee's needs, as the enrollee has a below-the-knee amputation. 
 
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 partial foot, molded socket. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee had a left foot amputation in 2023. He can perform ADLs but 
is unsteady with ambulation and uses a walker for assist. The enrollee has a left BKA and the request for a 
partial foot L5020 molded socket, tibial tubercle height, with toe filler is not appropriate for the enrollee's level 
of amputation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial foot, molded socket have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a partial foot, molded socket, tibial tubercle height, with toe filler (L5020).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99214) provided on June 29, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be paid. 
The Plan denied your request. The Plan says that evaluation and management codes are not covered for this 
specialty or provider type. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not substantiated why this provider cannot bill for this 
service. Therefore, we decided that the Plan has to pay for the office visit (99214) provided on June 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (77263, 99203, 99213) with an oncologist 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the enrollee must use network providers for most services. The service 
requested is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (77263, 99203, 99213) with an oncologist to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
August 26, 2021, to August 31, 2021 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
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 billed services. Our reviewer found that 
the enrollee was admitted to the SNF after an acute hospital stay due to acute encephalopathy with electrolyte 
disturbance. The documentation does not support the correct PDPM was submitted. The documentation 
available for review that pertains to the appropriate look-back period does not support that the enrollee has 
pertinent medical diagnosis to support the proposed PDPM code. The first, and third, alphanumeric character in 
the PDPM was not correct. The partial adjustment in this case was appropriate. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the skilled nursing facility (SNF) services provided from August 26, 2021, to August 31, 2021