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

 
We decided that the Plan does not have to pay for the EsoGuard Esophageal DNA test (0114U) provided on 
May 9, 2023. 
 
You asked the Plan to pay for the EsoGuard Esophageal DNA test (0114U). You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the EsoGuard 
Esophageal DNA test (0114U) is not covered by Medicare or the Plan. 
 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. This test is currently listed as not covered by Medicare in the DEX 
Diagnostic Exchange. Based on this information, we decided that Medicare rules for coverage of the EsoGuard 
Esophageal DNA test (0114U) have not been met. Therefore, we decided that the Plan does not have to pay for 
the EsoGuard Esophageal DNA test (0114U) provided on May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve clinical crown lengthening for tooth #30 . We decided that the 
Plan does not have to pre-approve pontics tooth # 3, #12 and #15, retainer crowns tooth # 2, #4, #11, #13, #14 
and #16 and clinical crown lengthening, hard tissue tooth #18.  
 You asked the Plan to pre-approve pontics tooth # 3, #12 and #15 (D6240), retainer crowns tooth # 2, #4, #11, 
#13, #14 and #16 (D6740) and clinical crown lengthening, hard tissue tooth #18 and #30 (D4249). You say that 
the tooth is cracked, and food can get inside, where you could possibly get an infection.  The Plan says that the 
services are not medically necessary. Remaining existing bridgework does not exhibit recurrent decay and thus 
does not warrant replacement. 
 
We decided that the Plan has to pre-approve clinical crown lengthening for tooth #30 .  
 
 Therefore, we decided that the Plan has to pre-approve clinical crown lengthening for tooth #30 .  
 
We also decided that the Plan does not have to pre-approve pontics tooth # 3, #12 and #15, retainer crowns 
tooth # 2, #4, #11, #13, #14 and #16 and clinical crown lengthening, hard tissue tooth #18. 
 
 Therefore, we decided that the Plan does not have to pre-approve pontics tooth # 3, #12 and #15, retainer 
crowns tooth # 2, #4, #11, #13, #14 and #16 and clinical crown lengthening, hard tissue tooth #18. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87481 and 87798) provided on March 11, 
2023. 
 
You asked the Plan to pay for procedure codes 87481 and 87798. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
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. 
 
We find that CPT codes 87481 and 87798 are not supported in the medical record. Specifically, a panel was 
performed and there is a more appropriate singular code for the services. 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 panel testing (87481 and 87798) provided on March 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the positive airway pressure (PAP) device (E0651) and 
humidifier (E0562). 
 
You asked the Plan to pre-approve the PAP device and humidifier. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the medical records do not show that member stops 
breathing in her sleep more than 10 times per hour. Additionally, the recent sleep study does not show that 
member has sleep apnea severe enough to require CPAP.  
 
he Plan follows Medicare rules. Medicare rules say that s PAP device is covered when the criteria listed in the 
Medicare Rules section is 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 the PAP device and humidifier. Our 
reviewer says that the enrollee does not need these items. Our physician reviewer found the patient does not 
have documentation of worsening sleep apnea or the requirement for humidification or requires a new machine 
with increased pressures. The humidification can be added to existing equipment, if needed.  The patient does 
not meet requirements for new equipment or CPAP therapy. 
 
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 PAP device and humidifier have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the positive airway pressure (PAP) device (E0651) and humidifier 
(E0562).
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 LTACH care is necessary. The Plan 
denied your request. The Plan says LTACH care is not medically necessary. 
 
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 there are no services available at the LTACH that the patient requires that are not 
available at the health care settings being offered by the Plan. Given there are offered alternatives, LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair and related accessories. 
 
You asked the Plan to pre-approve a wheelchair and related accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says Medicare does not cover wheelchairs when you live in 
a nursing home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair and related accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a wheelchair and related accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the patient's clinical condition meets full inpatient 
acute rehabilitation criteria. The Plan denied your request. The Plan says based on the available information, 
admission to an IRF is not reasonable and necessary.  
 
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 patient's nursing, medical and rehabilitation can be provided in 
a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Our reviewer also found that the patient requires treatment by multiple therapies, including 
physical therapy and occupational therapy, but this can be provided in a lower 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87631, 87635, 87798, 87801, 87641, 87500) 
provided on June 5, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 87631, 87635, 87798, 87801, 87641, & 87500 is not supported in the medical record. 
Specifically, multiple unbundled codes were billed for a single panel. 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 (87631, 87635, 87798, 87801, 87641, 87500) provided on June 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anticoagulant management provided on August 11, 2023, 
by an OON provider.  
 
You asked the Plan to pay for the anticoagulant management. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the anticoagulant management provided on 
August 11, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T12 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T12 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be 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 T12 kyphoplasty. Our reviewer says 
that the enrollee does not meet criteria for coverage. Our physician reviewer found the fracture is more than 12 
weeks old by history. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T12 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T12 kyphoplasty (22513).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) billed with procedure 
code G0482 provided on March 4, 2023. 
 
You asked the Plan to pay for procedure code G0482. You say that the definitive UDT testing (G0482) was 
medically necessary. The Plan denied your request. The Plan says the definitive UDT testing (G0482) was 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 procedure code G0482. Our reviewer says 
that the definitive UDT testing (G0482) was not medically necessary. Our physician reviewer found the 
documentation does not support that definitive multi-drug testing for up to 21 drug classes was 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 procedure code G0482 have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive urine drug testing (UDT) billed with procedure code G0482 provided on 
March 4, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF services to help with their 
walking and cognition. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record supports a need for 
multiple therapies. Additionally, there a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the record indicates that you have mild 
cognitive impairment. The record provided does not establish that you meet the diagnostic criteria of both 
Alzheimer's disease and frontotemporal dementia or that the examination is being requested in the context of a 
clinical trial. 
 
   
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305) provided on May 4, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim was not billed with a valid diagnosis code. 
 
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 88305 is not supported in the medical record. Specifically, code R13.10 Dysphagia, 
unspecified is not a valid diagnosis code for this service. 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 (88305) provided on May 4, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were independent before you were hospitalized, 
and you would like to return to being independent. The Plan denied your request. The Plan says you do not 
meet the criteria for an IRF admission. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollees condition is complex. However, the medical record significantly complies with the various 
documentation requirements for an IRF admission. There is every reason to expect the enrollee will participate 
in and benefit from the IRF level services, to include at minimum physical therapy, occupational therapy, 
physician oversight of polypharmacy, and case manager coordination of any additional services the enrollee 
may need to make a sustainable return home as well as avoid further preventable readmissions to the acute 
hospital. The requested IRF admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an outpatient diagnostic test provided on 
July 20, 2023. 
 
You asked the Plan to waive the cost share for an outpatient diagnostic test . You say that you disagree with the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient diagnostic tests/advanced 
Imaging Services.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic 
tests/advanced Imaging Services benefit category. You are being asked to pay $362.85 towards your $750 
deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to outpatient diagnostic tests/advanced Imaging Services. This cost sharing is a 
contractual obligation that had not been met at the time an outpatient diagnostic test was received on July 20, 2023. Therefore, we decided that the Plan does not have to waive the cost share for an outpatient diagnostic test 
provided on July 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82306, 82728, 83540, and 83550) 
related to end-stage renal disease (ESRD) provided on February 27, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (82306, 82728, 83540, and 83550) related to end-stage renal 
disease (ESRD) provided on February 27, 2023.