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

 
We decided that the Plan does not have to pay for the TissueCypher Barrett's Esophagus assay provided on 
March 3, 2023. 
 
You asked the Plan to pay for the TissueCypher Barrett's Esophagus assay. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing remains unproven for 
determining the risk of progression from Barrett's esophagus to high grade dysplasia or cancer. 
 
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 TissueCypher Barrett's Esophagus assay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the standard of care management of Barrett's esophagus depends 
on whether dysplasia is seen on histology. Dysplasia was not documented in enrollee's provided 
record. Available records do not support the medical necessity nor appropriateness in the enrollee's case of the 
intended predictive performance of TissueCypher, nor the extent to which the test results might alter medical 
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 TissueCypher Barrett's Esophagus assay have not been met. Therefore, we 
decided that the Plan does not have to pay for the TissueCypher Barrett's Esophagus assay provided on March 
3, 2023.
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 feel that the physicians know what is best and 
this should have been approved because inpatient rehabilitation is what my physicians wanted. The Plan denied 
your request. The Plan says the medical records do not show you have a new medical problem that would 
require treatment at least 3 times per week or rehabilitation nursing care 24 hours daily. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management (EM) services provided on April 21, 
2023, and April 24, 2023, billed with code 99349. 
 
You asked the Plan to pay for the EM services as billed. You say that this is correct billing as of 2023.  The 
Plan denied your request. The Plan says that code 99349 can only be reported with place of service (POS) code 
12. 
 
The Plan must follow Medicare rules. Medicare rules say that as of January 1, 2023, codes in the 99341 - 
99350 range can be used for services provided in a custodial care facility.  
 
We looked at the file and Medicare rules. As these services were provided in 2023, this code is now payable 
when reported in POS 33 for custodial care facility. Based on this information, we decided that Medicare rules 
for coverage of the EM services as billed have been met. Therefore, we decided that the Plan has to pay for the 
evaluation and management (EM) services provided on April 21, 2023, and April 24, 2023, billed with code 
99349.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support (bls), non-emergency 
transport (A0428), and ground mileage (V0425) provided on May 22, 2023. 
 
You asked the Plan to pay for ambulance service, basic life support (bls), non-emergency transport (A0428), 
and ground mileage (V0425). You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says based on the records received, the Medicare rules for coverage of non-emergency 
ambulance transportation and ground mileage have not been met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for ambulance service, basic life support (bls), 
non-emergency transport (A0428), and ground mileage (V0425). Our reviewer says that this does not meet 
criteria. Our physician reviewer found the records do not support that other means of transportation could have 
endangered the persons health. Our physician reviewer also found that the records do not support that other 
means of transportation by ambulance was medically required. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, basic life support (bls), non-emergency transport (A0428), 
and ground mileage (V0425) have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance service, basic life support (bls), non-emergency transport (A0428), and ground mileage (V0425) 
provided on May 22, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says SNF services are not medically necessary.  
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 that the clinical documentation does not support the medical necessity of daily skilled 
services on an inpatient basis in a skilled nursing facility. 
 
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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 8, 2022, to 
September 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
principal diagnosis A41.51 is supported in the documentation, therefore the claim should be paid at the DRG 
originally billed. The Plan denied your request. The Plan says A41.51 is not supported in the documentation. 
 
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 principal diagnosis A41.51, defined as sepsis due to 
Escherichia coli. 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 principal diagnosis A41.51 is not supported in the 
documentation. Our physician reviewer found the enrollee presented with evidence of systemic illness. They 
were found to have both pneumonia and a urinary tract infection (UTI). The enrollees overall state was 
attributed to the pneumonia. A specific cause for the pneumonia is not noted. The UTI was found to be due to 
Escherichia coli. As such, attributing the enrollees systemic illness to Escherichia coli and, therefore, A41.51, 
is not supported.  
 
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 on September 8, 2022, to September 21, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model 
without calibrated gradient pressure (E0651) and segmental pneumatic appliances, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that please see the 
clinical documentation to support medical necessity. The Plan denied your request. The Plan says under 
Medicare guidelines, this request is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device and 
appliances. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee with lymphedema in the lower extremities 
and was reported to have failed conservative therapy. The provided documentation did not sufficiently show 
evidence of a severe skin condition as required to justify this specific device. Therefore, the pneumatic 
compressor (E0651, E0667) will be considered not medically necessary based on the provided documentation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pneumatic compression device and appliances have not been met.  Therefore, 
we decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model without 
calibrated gradient pressure (E0651) and segmental pneumatic appliances, full leg (E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
May 12, 2023, and billed with codes 87511 and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary.  The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on May 12, 2023, and billed with codes 87511 and 87481.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the self-administered drugs received from December 12, 
2022, to December 19, 2022. 
 
You asked the Plan to pre-approve the self-administered drugs. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the self-administered drugs 
received from December 12, 2022, to December 19, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the pneumatic compression device (E0675) provided on 
February 22, 2023, through March 14, 2023. 
 
You asked the Plan to pay for  the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for the treatment of deep vein 
thrombosis during or after surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for  the pneumatic compression device (E0675) provided on February 22, 2023, through March 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 5, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that the coding is approved by Medicare. 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 NGS panel testing was not billed with a single 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 April 5, 
2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, 87500.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on September 21, 2022, billed with 
evaluation and management code 99213-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that payment for this service is included in another 
service. 
 
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 Plan denied this claim as being inclusive to another procedure. However, 
there is no evidence presented to identify which service the code at issue is inclusive to. As such, the denial of 
payment is not substantiated. Therefore, we decided that the Plan has to pay for practitioner services provided 
on September 21, 2022, billed with evaluation and management code 99213-25.  
 
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 unlisted molecular pathology procedure, Caris molecular 
profile comprehensive testing (81479) provided April 19, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with this determination and 
formally appeal and request a redetermination for the Plan's denial. The Plan denied your request. The Plan 
says this test is considered experimental and investigational. 
 
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. This test is not FDA approved and is not an approved companion 
diagnostic device. Based on this information, we decided that Medicare rules for coverage of the laboratory 
testing have not been met. Therefore, we decided that the Plan does not have to pay for unlisted molecular 
pathology procedure, Caris molecular profile comprehensive testing (81479) provided April 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide (G0156 x60). 
 
You asked the Plan to pre-approve the 60 home health aide visits. You say that the records provided support 
the need for the services in dispute. The Plan denied your request. The Plan says the services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 60 home health aide visits. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
clinical documentation does not specify any services that would require the assistance from a skilled home 
health aide. 
 
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 60 home health aide visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home health aide (G0156 x60).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 26, 2023. 
 
You asked the Plan to pay for the medical services. You say that all of the billed diagnosis codes are valid. The 
Plan denied your request. The Plan says the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that M51.16, M54.16, M51.86, and M47.897 have an Excludes1 note in 
relation to M47.896. This means that these diagnosis codes cannot be reported together. Based on this 
information, we decided that the Medicare billing rules for the medical services have not been met. Therefore, 
we decided that the Plan does not have to pay for medical services provided on April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4557 billed for date of service March 20, 
2023. 
 
You asked the Plan to pay for procedure code A4557. The Plan denied your request. The Plan says procedure 
code A4557 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code A4557 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4557 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4557 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4557 billed for date of service March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on March 15, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lift chair (A9270), sales tax (S999), and delivery (A9901). 
 
You asked the Plan to pay for a lift chair, sales tax and delivery. You say that the items should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly for the durable medical 
equipment and sales tax and delivery are not covered services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment.   
You have been asked to pay a 20% coinsurance for a lift chair, sales tax and delivery. This item/service falls 
within the durable medical equipment benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for a lift chair 
(A9270), sales tax (S999), and delivery (A9901).