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

 
We decided that the Plan does not have to pay for the genetic testing provided on October 12, 2022, billed with 
codes 81225, 81227, 81231, 81232, 81306, and 81335. 
 
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 
October 12, 2022, billed with codes 81225, 81227, 81231, 81232, 81306, and 81335.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (36415, 83550, 80053, 82607, 82728, 
82746, 84443 and 85025) billed for date of service November 22, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical records. The Plan denied your request. The Plan says the payment for these services is bundled 
into the payment for other services provided on this date. The Plan must follow Medicare rules. Medicare rules say that HCPCS codes that meet the criteria for payment 
of the composite APC are billed on the same date of service, CMS makes a single payment for all of the codes 
as a whole, rather than paying individually for each code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the record indicates that the Plan has made a 
payment for the services received as a whole. No separate payment may be made for individual codes with a 
status indicator of Q4 such as the codes at issue. Therefore, we decided that the Plan does not have to pay for 
laboratory services (36415, 83550, 80053, 82607, 82728, 82746, 84443 and 85025) billed for date of service 
November 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from November 10, 
2022, to November 25, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
have billed the services at issue correctly. The Plan denied your request. The Plan says records do not support 
the DRG originally billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, J96.01, defined as Acute 
respiratory failure with hypoxia. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the services at issue do not meet criteria 
for payment at the DRG originally billed. Our physician reviewer found that the provided documentation 
described the enrollee without respiratory distress, no accessory muscle use, unlabored breathing at rest, clear 
lung examination, on low dose oxygen support only. The patient did not require bi-level positive airway 
pressure (BiPAP), vent support or high-flow oxygen support. There was insufficient support in the provided 
documentation for the diagnosis of acute respiratory failure with hypoxia (J96.01).   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from November 10, 2022, to November 25, 2022, at the DRG originally 
billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
foot orthotics to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator. 
 
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 that the services are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has multiple comorbidities, 
including chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome (OHS), and 
chronic respiratory failure with hypercapnia. She would benefit from home ventilation and it would reduce 
readmissions and disease exacerbation. The home ventilator meets the criteria for coverage and is reasonable 
and 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 been met. Therefore, we decided that the Plan has to pre-
approve a home ventilator.  
 
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: 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 requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says criteria for admission to the acute IRF 
setting have not been met.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. 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 the medical services provided on February 2, 2023. 
 
You asked the Plan to pay for the medical services. You say that you were told that this provider was in-
network and you do not believe this should be denied.  The Plan denied your request. The Plan says that you 
were seen by a provider who is not contracted with your Plan, and without prior authorization. This claim was 
correctly denied.  
 
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. We find that the Plan has not provided sufficient information to determine that 
the denial of payment is correct given your argument. You have indicated that you were originally assigned a 
primary care physician (PCP) did not accept primary care patients. You stated that you were given the name of 
another doctor by the Plan, and this is the office you were seen in. Although the provider listed is out-of-
network (OON), we determined that the provider is a nurse practitioner (NP) who works at the same office as 
the network provider you were given by the Plan. The Plan did not confirm whether you were seen by this NP 
working under the network provider. The Plan did not provide any information or rebuttal to these facts you 
presented. Given the available information, there is insufficient evidence to conclude this denial is appropriate.  
Therefore, we decided that the Plan has to pay for the medical services provided on February 2, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code J7324 billed for date of service October 28, 2022.  
 
You asked the Plan to pay for code J7324. 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 J7324 is 2 The MAI value for this code is 2. You billed 168 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 
J7324 have not been met. Therefore, we decided that the Plan does not have to pay for code J7324 billed for 
date of service October 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services provided on September 10, 2022. 
 
You asked the Plan to pay for the genetic testing services . You say that the records provided support that the 
services provided were medically necessary.  The Plan denied your request. The Plan says screening genetic 
testing is not a covered service under 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 pay for the genetic testing services. Our reviewer 
says that the requested genetic testing services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has diagnoses of Bloom syndrome, chronic bronchitis, allergic 
rhinitis, osteoporosis, osteoarthritis, and low back pain. There is no personal history of cancer. 
 
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 genetic testing services have not been met. Therefore, we decided that the 
Plan does not have to pay for genetic testing services provided on September 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT genetic panel (81455) provided on December 
15, 2022. 
 
You asked the Plan to pay for the Tempus xT genetic panel. You say that this testing is medically necessary. 
The Plan denied your request. The Plan says the requested test is not reasonable and necessary because the 
clinical information submitted does not support advanced, refractory, metastatic or recurrent Stage III or IV 
cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS testing is covered when the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. In this case the record does not show that the enrollee has either 
recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this information, we 
decided that Medicare rules for coverage of the Tempus xT genetic panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the Tempus xT genetic panel (81455) provided on December 15, 
2022.
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to pay for the SNF services billed with a payment code including a diagnosis of 
concurrent dialysis. We decided that the Plan does not have to pay for the SNF services billed with a payment 
code including a PT/OT and skilled nursing score of 0-5.  
 
You asked the Plan to pay for the skilled nursing facility (SNF) services provided from May 1, 2022, to May 7, 
2022, with the payment code including a physical therapy (PT)/occupational therapy (OT) score of 0-5, a 
skilled nursing score of 0-5, and a diagnosis of concurrent dialysis. You say that this was billed correctly and 
should be paid at the billed payment level. The Plan says that the findings on the billing form are not supported.  
 
We decided that the Plan has to pay for the SNF services billed with a payment code including a 
diagnosis of concurrent dialysis.  
 
The Plan follows Medicare rules. Medicare rules say that SNF payment is made based on a PPS, and the HIPPS 
payment code for payment is calculated based on an assessment of diagnoses and functional abilities.   
 
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 services billed with a payment code 
including a diagnosis of concurrent dialysis. Our reviewer says that the records support that the enrollee was 
actively receiving dialysis during the dates at issue. However, our reviewer found that the functional scores that 
were reported were not supported.  
 
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 services billed with a payment code including a diagnosis of 
concurrent dialysis have been met. Therefore, we decided that the Plan has to pay for the SNF services billed 
with a payment code including a diagnosis of concurrent dialysis.  
 
We also decided that the Plan does not have to pay for the SNF services billed with a payment code 
including a PT/OT and skilled nursing score of 0-5. 
 
See above for the applicable Medicare rule and our physicians decision. 
 
 
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 services billed with a payment code including a PT/OT and skilled 
nursing score of 0-5 have not been met. Therefore, we decided that the Plan does not have to pay for the SNF 
services billed with a payment code including a PT/OT and skilled nursing score of 0-5. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee was referred by their internist 
for myoelectric orthotic restoration using the MyoPro Motion G. The Plan denied your request. The Plan says 
this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in 
those with stroke and hemiparesis. 
 
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 the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
and related supplies (E2103, A4239) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM and supplies. You say that the medical records 
provided will show proof of medical necessity. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a Freestyle Libre 2 continuous glucose monitor (CGM) and related supplies (E2103, A4239) to be provided by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided June 27, 2022, to June 29, 
2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee needed to be admitted to 
the hospital. The Plan denied your request. The Plan says that this admission was correctly denied. 
 
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 enrollee was admitted with right leg redness and fever. the record showed that at the time of 
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
(including earlier 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 June 27, 2022, to June 29, 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve social day care services. 
 
You asked the Plan to pre-approve social day care services. You say that you need these services. The Plan 
denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of social day care services have not been met. Specifically, we find that the services at issue in this 
case are not covered. Therefore, we decided that the Plan does not have to pre-approve social day care services.