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

 
We decided that the Plan has to pay for chemotherapy infusion and laboratory services provided on 
December 8, 2022. 
 
You asked the Plan to pay for chemotherapy infusion and laboratory services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that while this service or supply itself is not 
excluded, it is performed in connection with another service or supply that falls within this exclusion.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for chemotherapy infusion and 
laboratory services provided on December 8, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implantable loop recorder (33285) provided on January 
17, 2023. 
 
You asked the Plan to pay for the implantable loop recorder. The Plan denied your request. The Plan says this 
service 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 implantable loop recorder. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while the patient has a history of atrial flutter, there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent indication for an ILR. Our 
reviewer also found that in summary, there is insufficient documentation to support the medical necessity for 
insertion of an ILR in this patient's 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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pay for the implantable loop recorder (33285) provided on January 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service April 6, 2023, to 
May 5, 2023. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 6, 2023. The NOA was not received by the Plan until July 5, 2023. As 
more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on this 
claim. Therefore, we decided that the Plan does not have to pay for the home health services for date of service 
April 6, 2023, to May 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 20, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. 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 related to end-stage renal disease (ESRD) provided on 
February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute grafts. 
 
You asked the Plan to pre-approve skin substitute grafts. You say that it is medically necessary. The Plan 
denied your request. The Plan says it is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve skin substitute grafts. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not clearly show the enrollee with a non-healing 
ulcer. There were no prior measurements provided to compare to the more recent wound measurement to 
compare the change following standard treatment. Also, the product requested, Kerecis, is not listed as an 
approved product due to lack of sufficient supportive evidence. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin substitute grafts have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skin substitute grafts.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 4, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. 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 
February 4, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479 and 81238.
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 these services are medically necessary for the 
enrollee to regain their independence. The Plan denied your request. The Plan says the required services can be 
provided in an alternate setting.  
 
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 enrollee's functional status can be rehabilitated without admission to an IRF. Her 
level of function can be addressed at a lower level of care. She does not require intensive or complex 
rehabilitation services and does not require frequent physician oversight.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says that facet joint 
injections 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 the injections. Our reviewer says that 
facet joint injections are not medically necessary. Our physician reviewer found that the absence of 
documentation does not support the performance of diagnostic medical branch blocks. Therefore, the request 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on January 19, 2023, billed 
with codes 87486, 87498, 87496, 87502, 87532, 87541, 87581, 87640, 87651, 87798 and U0005. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was medically necessary and 
is supported in the medical record. 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 a 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 laboratory 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 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on January 19, 2023, billed with codes 87486, 87498, 87496, 87502, 87532, 87541, 87581, 
87640, 87651, 87798 and U0005.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle (scooter) 
(K0801). 
 
You asked the Plan to pre-approve a scooter. You say that you cannot walk, and the provider keeps sending the 
durable medical equipment (DME) provider the incorrect paperwork. The Plan denied your request. The Plan 
says the request for a scooter (K0801) is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a scooter. Our reviewer says that you 
do not meet the criteria for coverage. Our physician reviewer found the documentation available for review 
does not support that you require a power mobility device to accomplish mobility related self-care tasks in the 
home. Our reviewer also found that there is no indication that you are unable to use an alternative assistive 
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 a scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a group 1 heavy duty power operated vehicle (scooter) (K0801).  
 
Your complaint about your primary not following through with any of your needs is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
   
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 12, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips. 
 
You asked the Plan to pre-approve additional trips. The Plan denied your request. The Plan says this request 
exceeds the benefit allowance of 24 one-way trips per Plan year. 
 
 
 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 a maximum of up to 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have, or will have exhausted the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve additional trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility physician visit provided on March 31, 
2023. 
 
You asked the Plan to pay for nursing facility visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this code is only payable once every 14 days and the Plan already paid a 
claim for 99308 on March 24, 2023. 
 The Plan must follow Medicare rules. Medicare rules say that codes 99307, 99308, 99309, and 99310 are only 
allowed once every 14 days when billed with POS code 02.  
 
We looked at the file and Medicare rules. This code is not payable because it was performed less than 14 days 
following a covered billing of code 99308 with POS code 02. Based on this information, we decided that 
Medicare rules for coverage of nursing facility visit have not been met. Therefore, we decided that the Plan 
does not have to pay for a nursing facility physician visit provided on March 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided from April 7, 2023, to April 12, 2023. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The submitted 
delivery ticket is date April 5, 2023, which does not correspond with the dates of service in question. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supplies provided from April 7, 2023, to April 
12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 28, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 for date of service May 1, 2023, to 
May 2, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 
 We find that CPT code 99233 is not supported in the medical record. Specifically, the documentation does not 
include the total time spent on this service. A total time of 50 minutes or more must be shown in the 
documentation for this code to be covered. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99233 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99233 for date of service May 1, 2023, to May 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (E1230). 
 
You asked the Plan to pre-approve a power scooter. You say that your walker is not enough to support you for 
your daily activities. You also say that you need a scooter to continue with your daily activities to ensure a 
better quality of life for yourself. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power scooter. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found there is no evidence provided that you 
require a powered mobility device to complete MRADLs in the home. Our reviewer also found that there is no 
evidence the scooter is appropriate for your home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (E1230).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing and home health aide 
(G0299 x5, G0300 x12, G0156 x30). 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found documentation 
does not specify any acute clinical status, medication changes or plan of care changes. The records do not show 
that skilled nursing services are required in the home setting to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the enrollee's condition and/or prevent deterioration. Additionally, no care plan requiring the skilled 
service of professional staff is specified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing and home health aide (G0299 x5, G0300 x12, G0156 
x30).