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

 
We decided that the Plan does not have to pay for procedure code 87506 provided on January 21, 2022. 
 
You asked the Plan to pay for procedure code 87506. 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 supported. 
 
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 87506 is Infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
We find that CPT code 87506 is not supported in the medical record. Specifically, the record shows that more 
than 11 targets were tested. There is a more appropriate code for the services provided. Based on this information, we decided that Medicare rules for coverage of procedure code 87506 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 87506 provided on January 21, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the women's health polymerase chain reaction (PCR) panel 
testing provided on April 11, 2023. 
 
You asked the Plan to pay for the women's health PCR panel testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says more research is needed to show safety and efficacy of 
the procedure. 
 
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 women's health PCR panel testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that provided records in this case are limited to the test requisition and the 
test results with no additional medical records showing the test was furnished in a setting appropriate to the 
enrollee's medical needs and condition, that the test meets, but does not exceed the enrollee's medical need and 
that the test is not mainly for the convenience of the enrollee or the physician. 
 
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 women's health PCR panel testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the women's health polymerase chain reaction (PCR) panel testing 
provided on April 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion therapy (S9325, S9328). 

You asked the Plan to pre-approve home health services. You say that the requested home infusion therapy is 
medically necessary. 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 that based on 
the documentation provided, the health plan's denial should be upheld. You have chronic back pain, for which 
an intrathecal pump was placed in 2020. You had the pump refilled at a doctor's appointment on June 20, 2023. 
A request has now been placed for home health services to maintain and refill the pump. There are insufficient 
records to show that you are homebound and, therefore, qualifies for home health 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home infusion therapy (S9325, S9328).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 4, 
2022, to October 11, 2022. 
 
You asked the Plan to pay for SNF care. You say that the service was authorized. The Plan denied your request. 
The Plan says you billed PDPM code KAKD which is not approved. 
 
The Plan follows Medicare rules. Medicare rules state that the prospective payment system (PPS) patient-drive 
payment model (PDPM) is structured using case-mix adjusted rate components. 
 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 this SNF 
patient-driven payment model (PDPM) code is not supported. Our physician reviewer found the documentation 
available for review that pertains to the appropriate look-back period does not support the billed PDPMC of 
KAKD. The second and fourth alphanumeric character in the PDPM was not correct. Partial adjustment to 
PDPM KDKE1 was appropriate. 
 
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 skilled nursing facility (SNF) care provided from October 4, 2022, to October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20611 billed for date of service May 17, 
2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed code is not supported. 
 
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 20611 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting. 
 
We find that CPT code 20611 is not supported in the medical record. The records do not include a permanent 
recording and reporting for the ultrasound guidance. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20611 billed for date of service May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99215, 10060) provided on March 27, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (99215, 10060) is included in the 
global surgery payment for the procedure (10060) provided on March 25, 2023, which has a 10-day global 
period. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for the services (99215, 10060) provided on 
March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on April 24, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global surgery payment 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (99223) is included in the global 
surgery payment for the procedure (31500) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the services (99223) provided on April 24, 2023.
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 the enrollee's acute needs have been met 
and stabilized in the acute care setting. You say the enrollee is stable to transfer to the LTACH for the 
continuation of care in the long term acute care setting. The Plan denied your request. The Plan says criteria for 
admission to the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 Our physician reviewer found the documentation does not support that the enrollee requires services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the Plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not show an absence of 
untreated nerve pain (neurogenic claudication) or untreated radiating arm pain from the enrollee's back 
(radicular pain). Additionally, the records do not rule out that the pain is felt from a place other than the 
enrollee's spine (non-facet etiology). The criteria for coverage are not met and the RFA is not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has no documented failure of 
bilevel positive airway pressure (BIPAP), hence, BIPAP has not failed. If average volume assured pressure 
support (AVAPS) is the goal option, BIPAP with AVAPS is an alternative option. There is no documented or 
supportive evidence that the enrollee required home ventilator at this junction. Requirements have not been 
met. 
 
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 (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93306 rendered on November 30, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 93306-XE (1 units) remains not supported. 
 
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 93306 is "Echocardiography, transthoracic, real-time 
with image documentation (2D), includes M-mode recording, when performed, complete, with spectral 
Doppler echocardiography, and with color flow Doppler echocardiography." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records submitted are not consistent with CPT 93306 having been rendered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 93306 rendered on November 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiofrequency ablation of the genicular nerves with 
fluoroscopic guidance described by codes 64640 and 77002 performed on May 23, 2023. 
 
You asked the Plan to pay for 64640 and 77002. You say that 64640 and 77002 should be covered because 
these services are supported in the record and were necessary. The Plan denied your request. The Plan says 
64640 and 77002 are denied because these services are considered to be experimental or investigational, and 
therefore not covered. 
 
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 64640 and 77002. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found radiofrequency ablation (RFA) of the genicular nerves is considered experimental/investigational. There 
are ongoing clinical trials of this procedure. Therefore, the request is deemed 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 64640 and 77002 have not been met. Therefore, we decided that the Plan does 
not have to pay for radiofrequency ablation of the genicular nerves with fluoroscopic guidance described by 
codes 64640 and 77002 performed on May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 21, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PGx Comprehensive Pharmacogenomic Panel provided 
on October 20, 2022. 
 
You asked the Plan to pay for the PGx Comprehensive Pharmacogenomic Panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says there is no documentation of a specific 
adverse drug reaction. There is no documentation from the provider documenting the drugs being considered 
for use, and no documentation as to how the results will impact treatment. 
 
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 PGx Comprehensive Pharmacogenomic 
Panel. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that there was no documentation of a specific adverse 
drug reaction. There was no documentation from the provider documenting the drugs being considered for use, 
and no documentation as to how the results would impact treatment. The review has determined that the 
items/services at issue in this case were 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 PGx Comprehensive Pharmacogenomic Panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the PGx Comprehensive Pharmacogenomic Panel 
provided on October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the supplies (A4239) provided on May 15, 2023. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that a supply 
allowance is billable once every 30 days, and a supply allowance was billed on April 23, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that a supply allowance is billable once every 30 days, and a 
supply allowance was billed on April 23, 2023. However, the Plan has not provided documentation showing 
that a supply allowance was billed within 30 days prior to the supplies billed in this case. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
supplies (A4239) provided on May 15, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hypnotherapy to be provided by a hypnotist. 
 
You asked the Plan to pre-approve hypnotherapy. You say that hypnotherapy has been covered the last two 
years and has helped you get off of oxycodone. The Plan denied your request. The Plan says an out-of-network 
provider must be eligible to participate in Medicare or the Plan, meaning they are licensed or certified by 
Medicare and by the state to provide health care services. Your provider does not have a Massachusetts license 
to practice Behavioral Health Outpatient services in Massachusetts. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 We looked at the file and Medicare rules. A hypnotist is not a provider or a supplier that is enrolled in the 
Medicare program. Therefore, we decided that the Plan does not have to pre-approve hypnotherapy to be 
provided by a Hypnotist.