Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 day system.  
 
You asked the Plan to pre-approve the FreeStyle Libre 14 day system. The Plan denied your request. The Plan 
says  the enrollee is presently not on insulin treatment, and also does not present a history of problematic 
hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Libre 14 day system. Our 
reviewer says that the FreeStyle Libre 14 day system is not medically necessary. Our physician reviewer found 
the criteria for CGM coverage require insulin use or low blood glucose sugar. Neither is present here and we 
are not told why the enrollee cannot check their blood glucose sugar with a meter to meet glucose monitoring 
needs. Hence, although the CMG might help the enrollee, criteria for coverage are not 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 the FreeStyle Libre 14 day system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a FreeStyle Libre 14 day system.
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 device is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for approval of the requested device. 
 
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 COPD and 
obstructive sleep apnea, on a continuous positive airway pressure (CPAP) device. An arterial blood gas done 
during a recent COPD exacerbation was consistent with acute on chronic hypercarbic respiratory failure. A 
home ventilator has been prescribed in the average volume-assured pressure support (AVAPS) mode, which 
can be provided with bilevel positive airway pressure (BiPAP). There is no evidence that BiPAP with AVAPS 
has failed as an outpatient, or that inspiratory pressures higher than those that can be provided with BiPAP are 
necessary. Alarms and backup battery are not 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 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 a transurethral waterjet ablation of prostate, including 
control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, 
cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed 
(0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of the requested 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 pre-approve transurethral waterjet ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee does not meet the criteria for approval of the requested 
transurethral waterjet ablation of prostate. Specifically, the records do not show that the enrollee has had a 
transrectal ultrasound or maximum urinary flow rate (Qmax).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transurethral waterjet ablation of prostate, including control of post-
operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, 
urethral calibration and/or dilation, and internal urethrotomy are included when performed (0421T).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99213) provided on October 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that payment is 
included in the surgery payment. 
 
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 payment is included in the surgery payment. However, the 
Plan has not provided documentation showing that surgery was provided on the date of service in question. The 
only other code that was billed on this date of service is 77002, which is a radiology service and not a surgical 
procedure. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided 
that the Plan has to pay for the services (99213) provided on October 28, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on February 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary and is supported 
in the medical record. 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 lab services (81479) provided on February 23, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a review of the current medical literature does not consider this service to be 
standard medical treatment for the diagnosis of 
lymphedema. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that L-Dex has been studied to detect sub-clinical lymphedema and in the PREVENT trial data, 92% of 
patients with eraly detection using L-Dex did not progress to chronic lymphedema. Therefore, in this case with 
the enrollee complaining of arm swelling after the sentinel node biopsy with risk of lymphedema, this is 
reasonable and medically necessary meeting the criteria 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve bioimpedance spectroscopy (BIS).  
 
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 MicroGen qPCR Wound Panel (0112U) provided on 
January 16, 2023.  
 
You asked the Plan to pay for the MicroGen qPCR Wound Panel. You say that this testing was essential to 
analyzing this enrollee's specific diagnosis and treatment plan. The Plan denied your request. The Plan says 
standard of care is well documented to consist of standard culture techniques for the pathogen of concern.  
 
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 MicroGen qPCR Wound Panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the longstanding standard of care for the evaluation of pathogens is the 
performance of both gram stain and wound culture and sensitivity. These laboratory tests are inexpensive, 
sensitive, and specific. It is unclear as to why this enrollees wound required polymerase chain reaction (PCR) 
testing as compared to gram stain and wound culture and sensitivity. Therefore, the PCR testing of this 
enrollees wound was 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 MicroGen qPCR Wound Panel have not been met. Therefore, we decided 
that the Plan does not have to pay for the MicroGen qPCR Wound Panel (0112U) provided on January 16, 
2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for a screening study for abdominal aortic aneurysm (76706) billed for date 
of service January 24, 2023. 
 
You asked the Plan to pay for a screening study for abdominal aortic aneurysm. You say that the services at 
issue were a necessity for your care. The Plan denied your request. The Plan says that rules for payment have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a clear rationale for denial nor supported 
its denial with documentation such as claims or medical records. It is the Plan's responsibility to support its 
denial with evidence. In this case, the Plan's denial has not been supported, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for a screening study for abdominal aortic aneurysm (76706) 
billed for date of service January 24, 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 two additional units of procedure code 88361 rendered on 
August 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 while the documentation does not support that excess units were provided, there was no specific 
rationale as required by the policy as to why the additional units needed to be performed. 
 
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 88361 is "Morphometric analysis, tumor 
immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or 
semiquantitative, per specimen, each single antibody stain procedure; using computer-assisted technology." 
 
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 six units (approved) plus two 
additional units of procedure code 88361 (morphometric analysis, tumor immunohistochemistry--WATS3D) 
were rendered on August 30, 2022. However, the provided documentation did not clearly explain why 
additional units were needed for this enrollee. Therefore, the request for two additional units will be considered 
not medically necessary based on the provided documentation. 
 
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 two additional units of procedure code 88361 rendered on August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have billed the services at issue correctly. 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 lab services provided on December 12, 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 the enrollee has been progressing but requires a more 
intensive therapy program. The Plan denied your request. The Plan says the enrollee does not have any 
objective evidence of unstable conditions requiring physician oversight. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. Medically necessary care can 
be provided in a different level of care. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a hospital outpatient clinic visit (G0463) billed for date of service 
January 12, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial indicates that the modifier reported on the claim at 
issue is inconsistent with the procedure code. The case record does not support that a modifier was reported on 
the claim. The Plan has not provided evidence that a modifier was used to bill the service at issue. It is the 
Plan's responsibility to support its denial with evidence. In this case, the Plan's denial has not been supported, 
so we must find in your favor. Therefore, we decided that the Plan has to pay for a hospital outpatient clinic 
visit (G0463) billed for date of service January 12, 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 GeneSight Psychotropic testing provided on February 1, 
2023. 
 You asked the Plan to pay for GeneSight Psychotropic testing. You say that this testing was necessary, and you 
should be reimbursed at the rate for a GeneSight Single Gene test (81226). The Plan denied your request. The 
Plan says based on the medical records, a single gene test is not an accurate description of the testing provided 
to this enrollee. The test ordered and performed in this case is the GeneSight Psychotropic panel, which is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that providers must report services correctly. Providers 
must report services with the correct CPT code. 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. The records provided indicate that the GeneSight Psychotropic panel 
was performed rather than a single test for the CYP2D6 gene (81226). This test is listed in the DEX database as 
non-covered. This determination was made and is specific to the test at issue. Based on this information, we 
decided that Medicare rules for coverage of GeneSight Psychotropic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for GeneSight Psychotropic testing provided on February 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care services (99223) billed for date of service 
March 20, 2023. 
 
You asked the Plan to pay for initial hospital care services. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for enrollees who are registered hospital 
inpatients or outpatients, the inpatient or outpatient hospital POS code would be reported regardless of where 
the face-to-face service takes place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of initial hospital care services have not been met. Specifically, the case record supports that the enrollee was in an outpatient observation status on the date of service at issue. The claim at issue was 
erroneously billed with an inpatient POS code. Therefore, we decided that the Plan does not have to pay for 
initial hospital care services (99223) billed for date of service March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 6, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this was medically necessary The Plan denied your 
request. The Plan says this was not authorized. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 6, 2023, by an 
out-of-network (OON) provider.