Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires an intermediate 
level of care, which can be provided at an LTACH. The Plan denied your request. The Plan says that the 
enrollee is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in general, LTACHs do not provide clinical services that are materially different 
than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care 
services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving 
care. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bioengineered skin substitute (BSS) provided on 
September 29, 2022, billed with code Q4173. 
 
You asked the Plan to pay for the BSS. You say that this was medically necessary and should be paid. The Plan 
denied your request. The Plan says the code used is not appropriate. 
 
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 Q4173 is Palingen or palingen xplus, per square 
centimeter. 
 
We find that CPT code Q4173 is not supported in the medical record. Specifically, the record shows that 
Axolotl graft was placed, not palingen or palingen xplus. Axolotl graft has a more appropriate code. Based on this information, we decided that Medicare rules for coverage of the BSS have not been met. Therefore, we 
decided that the Plan does not have to pay for the bioengineered skin substitute (BSS) provided on September 
29, 2022, billed with code Q4173.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the Prolia (J0897). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says that the step therapy rules are not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the records show that the Plan preferred drug would be unsafe or ineffective. The review has determined 
that the documentation supports that Prolia is medically reasonable and necessary for the enrollee. The records 
show a trial of oral bisphosphonates. 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve the Prolia (J0897).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transportation (A0428, A0425) 
provided on December 8, 2022. 
 
You asked the Plan to pay for non-emergent ambulance transportation. You say that non-emergent ambulance 
transportation was a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
services at issue were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules. 
 
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 non-emergent ambulance transportation. Our 
reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation does not support that other means of transport (such as 
stretcher van, wheelchair van, taxi, private car or other type of vehicle) were contraindicated for the enrollee on 
December 8, 2022. The documentation does not support that the enrollee needed the expertise, services and 
lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergent ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transportation (A0428, A0425) 
provided on December 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service December 
30, 2022. 
 You asked the Plan to pay for procedure code 99284. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 99284 is bundled into payment for 
code 99285. 
 
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 99284 
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 99284 billed for date of service December 30, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 30, 2022, billed 
with codes 81408, 81407, 81406, 81161, 81405, 81404, 81403, and 81400. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 30, 2022, billed with codes 81408, 81407, 81406, 81161, 81405, 81404, 81403, and 81400.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need 
transportation to see a cancer surgeon. The Plan denied your request. The Plan says the requested trip exceeds 
your mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. In this case the requested trip is greater 
than 50 miles of driving distance. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 22, 
2022, through August 24, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was admitted due to 
inability to ambulate as well as acute on chronic back pain in addition to opioid therapy for pain and potential 
need for pain management. You states the enrollee was on oral analgesics after the first midnight. The Plan 
denied your request. The Plan says the enrollee was approved for observation services.  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee tolerated oral analgesics soon after initial treatment. The enrollee was 
stable otherwise. Therefore, it was not expected that the enrollee would require hospital care that would likely 
cross two (2) midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from August 22, 2022, through August 
24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from 
June 14, 2022, to June 30, 2022. 
 You asked the Plan to pay for the SNF care. You say that the discharge summary from the hospital documents 
the active diagnoses. The Plan denied your request. The Plan says the submitted documentation does not 
support the billed PDPM code. 
 
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 SNF care. Our physician reviewer found 
per coding rules, the Plan has adjusted the billing code correctly based on seven (7) day look back. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) services rendered from June 14, 2022, to June 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
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 lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services provided on October 26, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CardioMEMS device (33289) provided on September 21, 
2022. 
 
You asked the Plan to pay for the CardioMEMS device. You say that medical records to support the medical 
necessity of this device were provided. The Plan denied your request. The Plan says the device 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 pay for the CardioMEMS device. Our reviewer says that the CardioMEMS device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a lack of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. Therefore, the reviewer found that 
the CardioMEMS system is not medically appropriate and necessary in the enrollees clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pay for the CardioMEMS device (33289) provided on September 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review has determined that the record did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGx Comprehensive Complete Cancer Genetic Panel 
(81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 81314, 81334, 81345, 
81272, 81479) provided on December 6, 2022. 
 
You asked the Plan to pay for the CGx Comprehensive Complete Cancer Genetic Panel. You say that this test 
was medically necessary. The Plan denied your request. The Plan says this test should be billed with a single 
panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based on this information, we decided that Medicare rules for coverage of the CGx Comprehensive Complete Cancer 
Genetic Panel have not been met. Therefore, we decided that the Plan does not have to pay for the CGx 
Comprehensive Complete Cancer Genetic Panel (81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 
81321, 81351, 81209, 81314, 81334, 81345, 81272, 81479) provided on December 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx (0339U) provided January 11, 2023. 
 
You asked the Plan to pay for genetic testing. You say that the test was requested directly from the treating 
physician who makes the professional determination of diagnosis and medical necessity to successfully treat the enrollee. The Plan denied your request. The Plan says under the Medicare rules the request for SelectMDx 
is not medically necessary because this is not a test which has met the coverage criteria for reasonable and 
necessary by the MolDX technical assessment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
SelectMDx (0339U) provided January 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed with code G0482 for October 24, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0482 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 G0482 is definitive drug testing, 15-22 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records show that only 
nine drug classes were tested. 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 pay for the drug testing billed 
with code G0482 for October 24, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from December 7, 2022, 
through December 9, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says that the stay was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that your necessary hospital care (including earlier emergency 
department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from December 7, 2022, through December 9, 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 99213 provided on June 8, 2022. 
 
You asked the Plan to pay for procedure code 99213. You say that the medical records support the billing of 
code 99213 provided on June 8, 2022. The Plan denied your request. The Plan says the medical records do not 
support the billing of code 99213 provided on June 8, 2022. 
 
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 99213 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is 
spent on the date of the encounter. 
 
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 procedure code 99213. Our reviewer says that the medical 
records do not support the billing of code 99213 provided on June 8, 2022. Our reviewer found the 
documentation indicates that there was no low level of medical decision making provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99213 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99213 provided on June 8, 2022.