Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
  You asked the Plan to pre-approve the injections. You say that the enrollee has had a positive response from 
the first diagnostic lumbar medial branch block with over 80% overall improvement in their back pain as well 
as an ability to do more activities with less pain. The Plan denied your request. The Plan says facet joint 
injections are 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 injections. Our reviewer says that 
facet joint injections are not medically necessary. Our physician reviewer found that the medical records do not 
show that the enrollee has tried and failed different types of non-surgical treatment for three months before this. 
Therefore, the enrollee does not meet the LCD coverage criteria. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the semi-electric hospital bed (E0260) purchased February 16, 2023. 
 
You asked the Plan to pay for the hospital bed. You say that the bed and mattress are needed medical 
equipment for bed sores that developed due to sleeping on a conventional bed and mattress. The Plan denied 
your request. The Plan says that the purchased equipment did not meet Medicare guidelines for coverage, was 
obtained after notification of denial by the Plan. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 hospital bed. Our reviewer says that the 
requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is noted to have multiple pressure wounds, one of which is a stage II coccygeal pressure 
wound. The enrollee does not have the ability to re-position themself and requires frequent re-positioning given 
the pressure wounds. The enrollee is currently receiving wound care for pressure wound and this cannot be 
accomplished with an ordinary bed. Therefore, the requested semi-electric hospital bed (E0260) is medically 
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 hospital bed have been met. Therefore, we decided that the Plan has to pay 
for the semi-electric hospital bed (E0260) purchased February 16, 2023.  
 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 testing provided on July 10, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one HCPCS/CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a panel test that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on July 10, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA testing (81479) provided on July 24, 2023. 
 
You asked the Plan to pay for PrismRA testing. You say that this test was necessary and was reported 
appropriately. The Plan denied your request. The Plan says This test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as not having coverage set or 
approved. Based on this information, we decided that Medicare rules for coverage of PrismRA testing have not 
been met. Therefore, we decided that the Plan does not have to pay for PrismRA testing (81479) provided on 
July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service May 17, 2023. 
 
You asked the Plan to pay for the lab testing. You say that the use of the modifier was appropriate. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that diagnosis code group R11 has an Excludes1 note in relation to F50.89. 
This means that diagnosis codes R11.0 and F50.89 cannot be reported together. Based on this information, we 
decided that the Medicare billing rules for the lab testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing billed for date of service May 17, 2023.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for SNF care provided from December 14, 2022, to December 
21, 2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee had a need for the SNF services provided. 
The Plan denied your request. The Plan says the enrollee did not meet the criteria for SNF services during the 
period in question. 
 
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 pay for 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 there is no evidence that the enrollee received skilled nursing or skilled therapy 
during this time. Based on the documentation provided the enrollee did not qualify for SNF coverage.  
 
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 pay for SNF care provided from December 14, 2022, to December 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 23, 2023, billed with 
codes 87481, 87798, 87801, and 87653. 
 
You asked the Plan to pay for the genetic testing billed. You say that lab results were provided. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. This 
NGS panel not billed with a single code as required. Based on this information, we decided that Medicare rules 
for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on March 23, 2023, billed with codes 87481, 87798, 87801, and 87653.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PancraGen test (81479) provided June 29, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that it is unusual that a prior authorization would be 
needed for a clinical laboratory test in which a physician deemed to be medically necessary. The Plan denied 
your request. The Plan says PancraGen testing 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 looked at the file and Medicare rules. There is insufficient evidence in published literature that the use of 
this test would improve overall health outcomes when compared to standard cytopathology analysis of the 
pancreatic cyst. This test has not been cleared by the FDA and has not been approved by the American Medical Association (AMA). 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 PancraGen test 
(81479) provided June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV) to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the POV from an OON provider. You say that you have been waiting for 
this scooter for over a year. You say that you really need this scooter and do not understand why it is being 
denied.  The Plan denied your request. The Plan says there are network providers in your area who can provide 
the item being requested. 
 
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 
a power operated vehicle (POV) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic test, a combinatorial pharmacogenic 
test (0345U), and MTHFR gene analysis (81291) provided on May 17, 2023. 
 You asked the Plan to pay for GeneSight Psychotropic test and MTHFR gene analysis. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services provided are not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the MTHFR gene is only covered in 
enrollees who are pregnant. GeneSight Psychotropic testing is specifically not covered. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee was pregnant. 
This means the genetic testing for MTHFR is not covered. The GeneSight Psychotropic testing is specifically 
not covered. Based on this information, we decided that Medicare rules for coverage of GeneSight 
Psychotropic test and MTHFR gene analysis have not been met. Therefore, we decided that the Plan does not 
have to pay for GeneSight Psychotropic test, a combinatorial pharmacogenic test (0345U), and MTHFR gene 
analysis (81291) provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies provided on May 15, 2023. 
 
You asked the Plan to pay for the nerve conduction studies. You say that you are asking for the submitted 
documents to be reviewed. 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 nerve conduction 
studies provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for corneal hysteresis determination provided on  
November 1, 2022. 
 
You asked the Plan to pay for corneal hysteresis determination. You say that this service is covered by 
Medicare in this jurisdiction. The Plan denied your request. The Plan says with the information we have, we 
cannot determine how the member came to the servicing provider, whether the services were performed as 
billed, or whether the services are 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 corneal hysteresis determination have 
been met. Therefore, we decided that the Plan does not have to pay for corneal hysteresis determination 
provided on November 1, 2022.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says  the enrollee's condition does not meet all the 
requirements for inpatient rehabilitation admission. The Plan says services may be provided at a lower level of 
care. 
 
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 the enrollee has an infected sacral ulcer and does not have complex wound care needs 
or have other needs that qualify for LTACH admission.  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
March 30, 2023, and billed with codes 87481, 87653, 87798, and 87801. 
 
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 March 30, 2023, and billed with codes 87481, 87653, 87798, and 87801.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze provided on July 28, 2023. 
 
You asked the Plan to pay for gauze. You say that you say that you have attached medical records for review. 
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 gauze provided on July 
28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the records do not show that it is medically 
necessary to be in an LTACH in place of an acute care hospital.  
 
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 there is no documentation indicating the medical necessity for admission to an 
LTACH. There are no services available at the LTACH that the enrollee requires that are not available at the 
health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are 
necessary for wound care. You also say the LTACH services are necessary, or you might lose your legs. The 
Plan denied your request. The Plan says you do not meet Medicare guidelines for services in an LTACH.  
 
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 there is no documentation indicating medical necessity for admission to an LTACH. 
You do not require services at the LTACH that are not available at the acute care hospital where you are 
currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively 
only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
April 6, 2023, and billed with codes 87481, 87798, and 87801. 
 
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 April 6, 2023, and billed with codes 87481, 87798, and 87801.