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

 
We decided that the Plan does not have to pay for the PrismRA testing (81479) provided December 7, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denial over coverage and payment for PrismRA testing. The Plan denied your request. The Plan says this test is 
not medically necessary because this test is not FDA approved.  
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. The PrismRA has not been cleared or approved by the FDA. Online 
search of the FDA list of cleared or approved companion diagnostic testing does not mention this PrismRA. 
Search of the DEX Diagnostic Exchange registry for the diagnostic program MolDX Technical Assessment, 
states that this PrismRA test is not covered. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the PrismRA testing (81479) provided December 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT 648 Solid Tumor Assay (81455) provided on 
January 6, 2023. 
 
You asked the Plan to pay for the Tempus xT 648 Solid Tumor Assay. You say that this testing 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 show that the Tempus xT 648 Solid Tumor Assay is not 
FDA approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xT 648 Solid Tumor Assay have not been met. Therefore, we decided that the Plan does not have to pay for the 
Tempus xT 648 Solid Tumor Assay (81455) provided on January 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart with quantitative evaluation of 
coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT scan. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that Medicare does not cover the requested service 
for screening purposes. 
 
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 scan. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that the coronary CT calcium score 
measurement is essentially used to decide about taking Statins for individuals with moderate risk of 
atherosclerotic cardiovascular disease (ASCVD) in 10 years. The enrollee is at higher risk and already on 
Statins, hence the recommended test will not add any benefit in risk stratification. 
 
 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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan of the heart with quantitative evaluation of coronary calcium (75571).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing billed with codes 80307 and G0483 for date of 
service August 16, 2022. 
 
You asked the Plan to pay for the drug testing. . You say that the lab report supports that 22 different drug 
classes were tested. The Plan denied your request. The Plan says the records do not contain documentation to 
support the coding criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill services correctly.  In this 
case, you billed drug testing codes that indicate that 22 or more drug classes were tested.  However, the lab 
report provided only shows that 12 distinct drug classes were tested.   
Specifically, the records indicate that the following drug classes were tested: 
 
1. Opiates 
2. Opioids 
3. Amphetamines 4. Benzodiazepines 
5. Muscle Relaxers 
6. Anticonvulsants 
7. Cannabinoids, natural 
8. Barbiturates 
9. Tricyclic Antidepressants 
10. Synthetic THC 
11. Cocaine 
12. Methylenedioyamphetamines 
 
As a result, a different code should have been used to bill for these lab services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing.  have not been met. Therefore, we decided that the Plan does not have to pay for 
drug testing billed with codes 80307 and G0483 for date of service August 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99285 and 93010 provided on November 6, 
2022.  
You asked the Plan to pay for procedure codes 99285 and 93010. You say that you would like the Plan to 
reconsider their denial of payment The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
Medicare guidelines say that ICD-10-CM has a coding convention that requires the underlying condition to be 
sequenced first, followed by the manifestation. In this case, E08.621 is a manifestation code and cannot be used 
as the primary or first-listed diagnosis code on the claim. Therefore, we decided that the Plan does not have to 
pay for procedure codes 99285 and 93010 provided on November 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease. The provided records document that the home ventilator is being requested for use in 
intelligent volume assured pressure support (IVAPS) mode with auto-EPAP (AE) which could be provided by 
a bilevel positive airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) and 
a back-up rate. The provided records do not document trial and failure of a BiPAP device with AVAPS and a 
back-up rate. The provided records in this case do not provide adequate detailed information to meet Medicare 
criteria for coverage of a ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. Therefore, 
the enrollee does not meet criteria for the requested 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513). 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met.  
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures are covered under certain circumstances. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no documentation of a trial of 
bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88364 billed for date of service June 14, 
2022.   
You asked the Plan to pay for procedure code 88364. You say that this service was medically necessary. 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 88364 is 3. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88364 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88364 billed for date of service June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided during your outpatient 
hospital stay from January 30, 2023, to February 6, 2023. 
 
You asked the Plan to pay for the medication. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided during your outpatient hospital stay from January 30, 2023, to February 6, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral cervical and bilateral thoracic trigger point 
injections (20553 x2). 
 
You asked the Plan to pre-approve trigger point injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the pain of active trigger points can begin as an acute 
single muscle syndrome resulting from stress overload or injury to the muscle, or can develop slowly because 
of chronic or repetitive muscle strain. 
 
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 trigger point injections. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found you do not meet the Major 
criteria of the diagnosis of trigger points. The requested procedure is not medically reasonable and 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 trigger point injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral cervical and bilateral thoracic trigger point injections (20553 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission for a facial surgery rendered on 
December 17, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says an inpatient stay was not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case.Our 
physician reviewer found that the enrollee presented with facial paralysis due to metastatic squamous cell 
carcinoma presented to the hospital for scheduled surgery (preauricular approach to the right intratemporal 
fossa for identification of the masseteric nerve branch of the trigeminal nerve with preservation of all overlying 
midface branches of facial nerve, facial nerve suture using an operating microscope, harvest fascia lata from 
left thigh, use of fascia lata for resuspension of paralyzed face). The procedure was performed without 
complication or expected long recovery. The enrollee's vitals were stable. The enrollee only required basic 
wound dressing care. Based on this low risk procedure and the enrollee's history not being significant for an 
unstable condition or high risk diagnosis., it was not expected that they would require services at the hospital 
that would likely cross 2 midnights. Inpatient admission did not appear to be necessary for this date 
(12/17/21).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient admission for a facial surgery rendered on December 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says at this point, the device should only be approved for patients enrolled in a clinical trial. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene panel testing (81455) provided December 
30, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that denial of this clam based on failure to obtain 
prior authorization is not appropriate. The Plan denied your request. The Plan says Under Medicare guidelines, 
this is not medically necessary because the Tempus xF test is not an FDA approved.  
 
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 laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Tempus Gene panel testing (81455) provided December 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0843) and related 
accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the requested 
power wheelchair and accessories are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that you are not at 
high risk for skin breakdown, do not use intermittent catheterization, and do not have spasticity. As the PWC 
base is not medically necessary, the requested accessories 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 2 power wheelchair (K0843) and related accessories.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2023, to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
referred by a network provider. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2023, to February 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on August 15, 
2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the patient could have been treated on an outpatient 
basis and inpatient hospitalization was not warranted. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was a then, 78-year-old male who presented to the emergency 
department (ED) on August 14, 2022, with chest pressure. He was started on an antibiotic for a presumed 
urinary tract infection for the previous 2 days. His past medical history included hypertension, hyperlipidemia, 
congestive heart failure, mitral valve annuloplasty with ring replacement (2014), and rheumatoid arthritis. His 
electrocardiogram showed no acute changes. He had a negative nuclear stress test 2 months ago. He was placed 
in observation August 14, 2022, at 16:39. The History & Physical documented: "chest pressure; appears more 
of musculoskeletal - moderate to severe tenderness over the left breast region". The cardiology consultation 
obtained on August 15, 2022, at 08:23 documented: "He has no acute EKG changes, and though the highly 
sensitive troponins are minimally elevated, there is no rise and fall to suggest an acute coronary syndrome." He 
was changed to inpatient status on August 15, 2022, at 09:10. He was discharged home the same day with order 
entered August 15, 2022, at 11:24. The record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on August 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical equipment billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for the medical equipment. You say that the items in dispute were billed correctly 
and the denial is not accurate. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid proof of delivery. Specifically, the 'proof of delivery' you provided as 
support for your appeal is for a totally different patient, at a different address, and the date of delivery is 
October of 2021 (a year prior to the date of service in question).  Therefore, we decided that the Plan does not 
have to pay for medical equipment billed for date of service October 13, 2022.