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

 
We decided that the Plan does not have to pay for the Invitae Melanoma panel with add on genes for date of 
service December 28, 2022. 
 
You asked the Plan to pay for the Invitae Melanoma panel with add on genes. 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 gene panels are covered when the test has 
satisfactorily completed a Technical Assessment (TA) by Molecular Diagnostic Services Program (MolDX) 
for the stated indications of the test. 
 
We looked at the file and Medicare rules. Review of the file shows that the servive at issue is the the Invitae 
Melanoma panel with add on genes. This panel is not listed as a covered test. In addition, the add on genes are 
not covered as they were billed as individual codes for a single panel. Based on this information, we decided 
that Medicare rules for coverage of the Invitae Melanoma panel with add on genes have not been met. 
Therefore, we decided that the Plan does not have to pay for the Invitae Melanoma panel with add on genes for 
date of service December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 5, 2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on December 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health nursing services. 
 
You asked the Plan to pre-approve home health nursing services. You say that the services are 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 provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate skilled nursing visits. No medical notes from your treating physician are provided 
documenting an order or need for skilled nursing services. Records do not document the need for intravenous 
medications, new tube feeding, or ostomy care or daily complex wound 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health nursing services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 94618-26 billed for date of service December 28, 2022. 
 
You asked the Plan to pay for code 94618-26. You say that this is not a duplicate claim. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 19, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for code 94618-26 have not been met.  Therefore, we decided that the Plan does not have to pay for code 94618-26 billed for date of service December 
28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a suprascapular nerve block (64418). 
 
You asked the Plan to pre-approve a nerve block. You say that the National Library of Medicine shows that 
this injection is a safe and effective method for providing anesthesia and analgesia for the shoulder. You also 
say that this is the appropriate treatment for the enrollee. The Plan denied your request. The Plan says the 
requested block 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 a nerve block. Our reviewer says that 
the requested nerve block is not considered medically reasonable and necessary in this case.  Our physician 
reviewer found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. There are no diagnostic imaging studies provided to corroborate left shoulder pathology. Also, the objective examination did not provide any shoulder deficits. 
There is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an 
effective and/or safe treatment for the noted pathology. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
suprascapular nerve block is 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 a nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a suprascapular nerve block (64418).
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 you are requesting an expedited 
reconsideration for the denial of an LTACH admission. 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 enrollee appears to be tolerating weaning and should only require short- 
term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and completion of treatment at the current facility is recommended.  
 
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 procedure code(s) 88346, & 88350 billed for date of service 
August 23, 2022. 
 
You asked the Plan to pay for procedure code(s) 88346, & 88350. You say that these services were medically 
necessary. The Plan denied your request. The Plan says this code is included in the skilled nursing facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT codes 88346, & 88350 have a Professional/Technical indicator of 1. This means that CPT codes 
88346, & 88350 have both a professional and technical component. In this case, CPT codes 88346, & 88350 
have not been billed with an appropriate modifier to indicate the professional component. Code 88350 is an 
add-on code billed without an appropriate primary procedure. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 88346, & 88350 have not been met.  Therefore, we decided 
that the Plan does not have to pay for procedure code(s) 88346, & 88350 billed for date of service August 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on January 6, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service December 
15, 2022. 
 You asked the Plan to pay for procedure code 88342. The Plan denied your request. The Plan says payment for 
code 88342 is bundled into payment for code 88184. 
 
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, we have confirmed that code 88342 
is a column II code to column I code 88184. Based on the claim submitted, Medicare billing criteria have not 
been met.  Therefore, we decided that the Plan does not have to pay for procedure code 88342 billed for date of 
service December 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6. 
 
You asked the Plan to pre-approve a Dexcom G6. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that only the preferred brand products listed in the 
EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a therapeutic continuous glucose monitor. Therefore, we decided that the Plan does not have to pre-approve 
a Dexcom G6.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for therapeutic, prophylactic, and diagnostic injections and infusions 
provided on September 6, 2022. 
 
You asked the Plan to pay for therapeutic, prophylactic, and diagnostic injections and infusions. The Plan 
denied your request. The Plan says that according to our records the precertification entity was not contacted 
for precertification.  
 
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 Plan rule or a Medicare rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for therapeutic, prophylactic, and 
diagnostic injections and infusions provided on September 6, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA). 
 
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 PTA 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 enrollee has documented severe 
lumbar spine disease. There is documentation of palpable pedal pulses on physical examination and essentially 
normal ankle-brachial indices (ABIs). There is no evidence of significant disease on duplex evaluation. Isolated tibial disease is not an indication for intervention. There is no suggestion of limb threat in the medical record or 
documentation of lifestyle-limiting claudication. With the enrollees comorbidities, it is unclear that the 
enrollee would derive any meaningful improvement in walking distance or quality of life with intervention. 
PTA is therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous transluminal angioplasty (PTA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power arm brace (MyoPro) (L8702).  
 
You asked the Plan to pre-approve MyoPro. You say that the enrollee needs this device for the treatment of 
right upper extremity partial paralysis. The Plan denied your request. The Plan says experimental and 
investigational procedures are not covered by Medicare. 
 
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 MyoPro. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollees condition or in widespread use for this enrollees condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for this enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power arm brace (MyoPro) (L8702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29879 billed for date of service January 26, 
2023.  
 You asked the Plan to pay for procedure code 29879. You say that the service was performed in two separate 
compartments of the knee. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29879 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 29879 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 29879 billed for date of service January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum assisted socket suspension (VASS) (L5781) 
and an alignable system (L5910). 
 
You asked the Plan to pre-approve a VASS and alignable system. You say that there is plentiful research 
studies supporting the efficacy for treating wounds in a socket, and it is widely accepted in the field and by 
Medicare. You also say that the alignable system is required to address the change in build height that the 
vacuum system creates to accommodate the pump. The Plan denied your request. The Plan says experimental 
and investigational items are not covered by Medicare. The Plan also says replacement alignable system 
exceeds the enrollee's need and is not reasonable and necessary for the approved replacement socket. 
 
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 VASS and alignable system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found the enrollee has had a recent replacement socket. The requested device has 
not been shown to be superior to other standard treatments for the medical condition. Our reviewer also found 
that the requested VASS for the prosthesis is 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 VASS and alignable system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a vacuum assisted socket suspension (VASS) (L5781) and an alignable 
system (L5910).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 19, 2022, to 
February 17, 2022. 
 
You asked the Plan to pay for May 25, 2022. You say that all of the required documents were submitted, so this claim should be paid in full. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 

The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care. 

In this case, the start of care date is January 19, 2022. The NOA was not received by the Plan until May 25, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from January 19, 2022, to February 17, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation provided on July 18, 2022. 
 
You asked the Plan to pay for the transportation. The Plan denied your request. The Plan says that the payment 
for the procedure was included in the hospital 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 hospital payment. However, the 
Plans has not provided a supporting Medicare rule for its denial. Without supporting documentation, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the ambulance transportation 
provided on July 18, 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.