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

 
We decided that the Plan does not have to pay for stress testing (93016, 93018) provided on October 4, 2022. 
 
You asked the Plan to pay for stress testing. You say that this service was medically necessary. 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 October 31, 2022. 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 stress testing have not been met. Therefore, 
we decided that the Plan does not have to pay for stress testing (93016, 93018) provided on October 4, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that it appears that you had reached a higher level of function as compared 
to your status prior to the initial admission to the acute hospital.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the health plans denial should be overturned. 
The health plan argues that your functional level was such that ongoing SNF care was not medically necessary.  
While the health plan cited records from March 20, 2023, March 23,2023, March 30, 2023, and April 4, 2023, 
no such records are identified for review.  As such, the health plan has failed to support its argument. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 pre-approve an infectious agent detection and identification, targeted 
sequence analysis with drug-resistance gene (0112U). 
 
You asked the Plan to pre-approve genetic testing. You say that the provider is appealing the medical necessity 
denial for Karius Genetic testing, due to the enrollee's disorder of the skin and subcutaneous tissue. The Plan 
denied your request. The Plan says the information provided does not show that the enrollee meets criteria for 
the ordered tests. 
 
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 genetic testing. 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 suppurative granulomatous skin disease and is requesting genetic testing. The 
enrollee has waxing and waning skin lesions that have recently worsened. The enrollee is not reported to be 
immunocompromised. The infectious disease provider noted that the enrollee has a history of a positive 
Quantiferon test, and she may have a mycobacterium disease. The provider is requesting 0112U, Karius test to 
evaluate the enrollee for identification of a possible etiology of her skin lesions. The Karius test is not 
considered a covered test by the Molecular Diagnostic Program (MolDX) demonstrating analytical validity, 
clinical validity and clinical utility. The review has determined that the items/services at issue in this case are 
not medically reasonable or necessary. The enrollee does not meet criteria for approval of the requested genetic 
testing. 
 
We looked at this physician's review, 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 pre-approve an infectious agent detection and identification, targeted sequence analysis with drug-
resistance gene (0112U).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravascular ultrasound (procedure codes 37252 and 37253) 
rendered on February 17, 2023. 
 
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 the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 37252: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to 
code for primary procedure) 
 
CPT 37253: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; each additional noncoronary vessel (List separately in 
addition to code for primary procedure) 
 
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 the denied codes are for 
supervision and interpretation of intravascular ultrasound (IVUS) imaging. There is inadequate detail with 
respect to IVUS findings that would justify the billing and coverage of these interpretation codes. 
 
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 intravascular ultrasound (procedure codes 37252 and 37253) rendered on February 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power scooter purchased on July 6, 2022. 
 
You asked the Plan to pay for the power scooter. You say that you understand the Plan will reimburse you 70% 
of the purchase price for the scooter. You also say that you cannot walk or stand without help. The Plan denied 
your request. The Plan says Medicare requires specific evaluations be done prior to approval of any power 
scooter. The Plan also says that you have not completed any of the necessary evaluations. 
 
The Plan must follow Medicare rules. Medicare rules say that prior to or at the time of delivery of a POV or 
PWC, the supplier or practitioner must perform an on-site evaluation of the beneficiarys home, and there must 
be a written report of this evaluation available on request. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the power scooter have not been met. Therefore, we decided that the Plan does not have to pay for 
the power scooter purchased on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Pap smear provided on February 8, 2023. 
 
You asked the Plan to pay for the Pap smear. You say that you were not informed of the change in the Pap 
smear benefit going from 12 months in 2022 to 24 months in 2023. The Plan denied your request. The Plan 
says in reviewing both EOCs for 2022 and 2023, there is no change in benefits. The Plan says in reviewing the 
claims history, the member previously had the same service in January of 2022. 
 
The Plan contract says Pap tests and pelvic exams are covered once every 24 months. 
 
We looked at the file and the Plans rules. The file shows that you have exceeded the benefit limit. Based on 
this information, we decided that the Plans rules for coverage of the Pap smear have not been met. Therefore, 
we decided that the Plan does not have to pay for a Pap smear provided on February 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on September 14, 2022, billed 
with codes 87799, 87482, 87186, and 87500. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you disagree with the Plan's 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 a 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 laboratory testing 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on September 14, 2022, billed with codes 87799, 87482, 87186, and 87500.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA). 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee received RFA on January 
9, 2023. The submitted records do not show the degree and duration of pain relief after this ablation. The 
criteria for coverage are not met and the repeat RFA is 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 repeat radiofrequency ablation (RFA).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for date of service January 18, 
2023. 
 
You asked the Plan to pay for the billed services. You say that  the drug was a necessary part of the enrollee's 
treatment. The Plan denied your request. The Plan says the service cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code J3490 was used to describe Bupivacaine, which is a local anesthetic and not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed for date of 
service January 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services billed with code J3490 for January 6, 2023. 
 
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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intraoperative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same day as 
minor surgical procedure 27096. Payment for code J3490 is included in the global surgical payment for code 
27096. Therefore, we decided that the Plan does not have to pay for the drug services billed with code J3490 
for January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service December 
16, 2022. 
 You asked the Plan to pay for procedure code 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 93016. 
 
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 99232 
is a column II code to column I code 93016. 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 99232 billed for date of service December 16, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital-care services (99233) provided on 
December 19, 2022. 
 
You asked the Plan to pay for subsequent hospital-care services. You say that you have correctly billed the 
services at issue. 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 the ICD-10-CM has a coding convention that 
requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of subsequent hospital-care services have not been met. Specifically, this claim has been billed with 
F05 as the primary diagnosis code. F05 has a code-first note, meaning that the underlying condition must be sequenced first on the claim. Therefore, we decided that the Plan does not have to pay for subsequent hospital-
care services (99233) provided on December 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says your records do not 
show the need for an admission to a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home ventilator. 
 
You asked the Plan to pre-approve home ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home ventilator. Our reviewer says that 
the documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of chronic respiratory failure consequent to chronic 
obstructive pulmonary disease. Provided records document that the home ventilator is being requested for use 
in average volume assured pressure support (AVAPS) mode with auto-EPAP (AE) which could be provided by 
a BiPAP device with AVAPS and a back-up rate. Provided records do not document trial and failure of a 
BiPAP device with AVAPS and a back-up rate. Therefore, the enrollee does not meet criteria for the requested 
device. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Percepta Classifier test rendered on November 28, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this does not meet the requirements for approval. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that records describe the enrollee with a history of a solitary pulmonary nodule (.30 mm) found on 
imaging with a 45 pack-year history of smoking describing an already high risk of malignancy. The criterion 
for this testing includes having a low or intermediate pretest risk of malignancy. As the enrollee has high 
pretest malignancy risk, appropriate screening/monitoring methods are already approved, and there is no other 
practical utility of the test for this enrollee. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for the Percepta Classifier test rendered on November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dayspring active compression system and garment. 
 
You asked the Plan to pre-approve Dayspring active compression system and garment. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are 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 Dayspring active compression system 
and garment. 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 a diagnosis of lymphedema. The records 
show that the enrollee has been non-compliant with proper compression wear (insisting on wearing them for 
sleeping for a few days at a time or wearing over the counter pantyhose). There is no evidence that the enrollee has used standard pneumatic compression for any significant length of time (there was notation of a brief trial 
of a standard pump at the time of Flexitouch demonstration). Therefore, the enrollee does not meet criteria for 
the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Dayspring active compression system and garment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Dayspring active compression system and 
garment.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent hospital care provided from June 29, 2022, to June 30, 
2022. 
 
You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the claim cannot be processed at this time. The Plan also says the 
charges are needed from the servicing provider. 
 
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 provided documentation does not support that the Plan did their due 
diligence to confirm if the services in this case were considered inpatient or not, nor did they reach out to the 
provider to request they submit a claim. Therefore, we decided that the Plan has to pay for the subsequent 
hospital care provided from June 29, 2022, to June 30, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.