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

 
We decided that the Plan has to pay for the Guardant Reveal Post-Surgery Minimal Residual Disease Bundle 
(81479) provided on October 7, 2022. 
 
You asked the Plan to pay for the Guardant Reveal Post-Surgery Minimal Residual Disease Bundle. You say 
that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says 
that 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 show that the required unique identifier 
was reported. Additionally, the Guardant Reveal Post-Surgery Minimal Residual Disease Bundle is also listed 
as covered in the DEX Diagnostics Exchange. Based on this information, we decided that Medicare rules for 
coverage of the Guardant Reveal Post-Surgery Minimal Residual Disease Bundle have been met. Therefore, we 
decided that the Plan has to pay for the Guardant Reveal Post-Surgery Minimal Residual Disease Bundle 
(81479) provided on October 7, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 25, 2022, 
to October 24, 2022.  
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 25, 2022, to 
October 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of Acute Inpatient 
Rehab Admission. The Plan denied your request. The Plan says the enrollee does not meet all of the 
requirements for IRF admission. 
 
  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 
will be able to fully participate in  and benefit from  the intensive rehabilitation therapy program provided in 
an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the records do not show support that the ventilator 
is needed for the enrollee's condition when not in an acute exacerbation or that she is unable to obtain the same 
benefit from a BiPAP with AVAPS. The request 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. Provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. Provided records 
document "BiPAP on standby, not in use." As stated in the Local Coverage Determination (L33800): "Claims 
for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will 
be denied as not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance 
(62323). 
 You asked the Plan to pre-approve injections. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no evidence of the return of moderate/severe pain, at least 50% for 3 months, 
and ongoing active conservative treatment from the last injection on February 10, 2023. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have chronic low back pain. You tried conservative therapy without significant 
improvement. You had L4-L5 ESI on February 10, 2023, and then this was repeated at the same level, same 
approach on March 2, 2023. The LCD criteria is documentation of 50% pain relief for 3 months. This was not 
achieved and 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), of diagnostic or therapeutic substance (62323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a secondary wheelchair. 
 
You asked the Plan to pre-approve repairs to a secondary wheelchair. You say that the repairs are necessary. 
The Plan denied your request. The Plan says you have a primary power wheelchair that you received in May of 
2020 that can meet your mobility needs. Per policy, authorization for repairs on a secondary or back-up patient 
owned wheelchair that is used in the home are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have power wheelchair. power wheelchair serves the same purpose as repairs to 
secondary wheelchair. Therefore, we decided that the Plan does not have to pre-approve repairs to a secondary 
wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart procedure. 
 
You asked the Plan to pre-approve Optimizer Smart. You say that you need this done as soon as possible. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Optimizer Smart. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not clearly show that the full workup for the cause of your 
symptoms was found to be heart failure. You have many potential causes. Also, records do not show that first 
and second-line treatments were optimized or tried and failed before considering this procedure. Current 
medical literature does not sufficiently show high-quality evidence to support the use of this device in this clinical setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Optimizer Smart have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Optimizer Smart procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 8, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
transported to the hospital. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 8, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120) provided on November 11, 2022. 
 
You asked the Plan to pay for the dentures. You say that you were unaware that the provider could not be 
excluded from and had opted out of Medicare. The Plan denied your request. The Plan says our we cannot 
reimburse you for dental services provided by an excluded provider or an opt-out provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a 
complete denture - maxillary (D5110), and complete denture - mandibular (D5120) provided on November 11, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0241U) provided on November 29, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. 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 the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(0241U) provided on November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis, double upright, thigh and calf, with 
adjustable flexion and extension joint (L1852). 
 
You asked the Plan to pre-approve a knee orthosis. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the request is not medically necessary because 
records show the enrollee does not have a recent injury to the knee or surgery to the knee. 
 
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 a knee orthosis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the orthosis is provided after an acute injury or if there is knee instability. The enrollee has 
chronic degenerative disease in her knee without instability. Per L33318, criteria is not met as stated above. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint 
(L1852).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraorafice barrier (D3911). 
 
You asked the Plan to pre-approve intraorafice barrier. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
intraorafice barrier (D3911).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 testing provided on September 30, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing assist physician's decision making. 
The Plan denied your request. The Plan says that the unique identifier was not billed as required. 
 
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. A review of the claim does show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage have been met. The Plan 
has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request.  Therefore, we decided that the Plan has to pay for the Guardant360 testing provided on 
September 30, 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 pay for procedure code S9328 billed for date of service December 
14, 2022, to December 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the Plan's denial. 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 December 14, 2022, to December 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bath/shower chair. 
 
You asked the Plan to pay for a bath/shower chair. You say that you had this code approved or else it would 
never have been delivered. You also say that the doctor put in a prescription for the chair and  it was approved. 
The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a bath/shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #23. 
 
You asked the Plan to pre-approve the dental service. You say that you thought a crown was covered every 32 
months and it is necessary to get a new crown. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of February 12, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #23.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350), limited oral evaluation - problem focused (D0140), comprehensive oral evaluation - new 
or established patient (D0150), intraoral - periapical first radiographic image (D0220), diagnostic casts 
(D0470), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including 
elevation of mucoperiosteal flap if indicated (D7210), periodontal scaling and root planing - four or more teeth 
per quadrant (D4341), and periodontal scaling and root planing - four or more teeth per quadrant (D5225) 
provided on July 5, 2022, to August 31, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you needed vascular surgery 
and were told to delay your dental care due to taking blood thinners and that it would affect your treatment. 
You also say that you were allowed to resume your dental care in July and August of 2022 after three years. 
The Plan denied your request. The Plan says your benefit for the comprehensive oral evaluation has already 
been exhausted. The Plan also says that the dental codes represented by D0350, D0140, D0220, D0470, D7210, 
D4341 and D5225 are not covered by the Plans dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for comprehensive oral evaluation was exhausted on date of service December 7, 2022, 
which is within the limitation. Although the date of service is after the members appealed date, the claim was 
processed prior. The dental codes represented by D0350, D0140, D0220, D0470, D7210, D4341 and D5225 are 
not among those covered under this benefit.  
 
 Therefore, we decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-
orally or extra-orally (D0350), limited oral evaluation - problem focused (D0140), comprehensive oral 
evaluation - new or established patient (D0150), intraoral - periapical first radiographic image (D0220), 
diagnostic casts (D0470), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and 
including elevation of mucoperiosteal flap if indicated (D7210), periodontal scaling and root planing - four or 
more teeth per quadrant (D4341), and periodontal scaling and root planing - four or more teeth per quadrant 
(D5225) provided on July 5, 2022, to August 31, 2022.