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

 
We decided that the Plan does not have to pay for Guardant Reveal laboratory testing provided on October 14, 
2022, billed with code 81479. 
 
You asked the Plan to pay for Guardant Reveal. You say that you are the only provider for this test. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 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. Review of the claim shows that the required unique identifier has 
been reported on the claim. However, the DEX Registry shows this test has a coverage status of not covered. 
Therefore, we decided that the Plan does not have to pay for Guardant Reveal laboratory testing provided on 
October 14, 2022, billed with code 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service July 20, 
2022. 
 You asked the Plan to pay for procedure code 0003A. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal laboratory testing provided on October 28, 
2022, billed with code 81479. 
 
You asked the Plan to pay for Guardant Reveal. You say that you are the only provider of this service. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 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. Review of the claim shows that the required unique identifier has 
been reported on the claim. However, the DEX Registry shows this test has a coverage status of not covered. 
Based on this information, we decided that Medicare rules for coverage of Guardant Reveal have not been met. 
Therefore, we decided that the Plan does not have to pay for Guardant Reveal laboratory testing provided on 
October 28, 2022, billed with code 81479.
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 services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH 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 that the enrollee appears to be improving with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for a lower level of care. The patient does not require services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary as it would not be 
clinically advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81351 billed for August 4, 2022. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that procedure code 81351 is non-covered. 
 
We looked at the file and Medicare rules. The services were billed with code 81351. This code is non-covered 
by Medicare. Therefore, we decided that the Plan does not have to pay for procedure code 81351 billed for 
August 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says the drug is being provided by a pharmacy and is not covered under the Part B 
medical benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Orthovisc.  
 
Benefits for Orthovisc 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided from November 23, 2021, to 
December 30, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the provider did supply evidence that claim was attempted to be billed once 
before, but provider failed to re-file claim within timely file, despite being timely notified of rejection of initial 
claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the nursing facility care was not filed until January 18, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for nursing facility care provided from November 23, 2021, to 
December 30, 2021.
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 services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH 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 that the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 
 
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 flexible silicone liner (L7499). 
 
You asked the Plan to pre-approve the flexible silicone liner. You say that this item is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services 
correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes 
the services performed. 
 
We looked at the file and Medicare rules. This feature is included in the approved prosthesis. Separately 
requesting code L7499 is considered unbundling. Based on this information, we decided that Medicare rules for 
coverage of the flexible silicone liner have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a flexible silicone liner (L7499).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 5, 2021, 
to July 6, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says the inpatient care was not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from July 5, 2021, to July 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis posterior or posterolateral technique single 
level (22614) and laminectomy, facetectomy and foraminotomy, single vertebral segment; each additional 
vertebral segment, cervical, thoracic, or lumbar (63048). 
 
You asked the Plan to pre-approve arthrodesis and laminectomy, facetectomy and foraminotomy. You say that 
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 arthrodesis and laminectomy, 
facetectomy and foraminotomy. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found physical exam findings do not correlate with the enrollee's imaging studies. Spinal instability is not present. Also, there is no recently 
documented 6 week trial of physical 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 arthrodesis and laminectomy, facetectomy and foraminotomy have not been 
met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis posterior or posterolateral 
technique single level (22614) and laminectomy, facetectomy and foraminotomy, single vertebral segment; 
each additional vertebral segment, cervical, thoracic, or lumbar (63048).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that these items are medically necessary. 
The Plan denied your request. The Plan says the requested items are non-covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided from September 22, 2021, to 
October 28, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the provider did supply evidence that claim was attempted to be billed once 
before, but provider failed to re-file claim within timely file, despite being timely notified of rejection of initial 
claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the nursing facility care was not filed until January 18, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for nursing facility care provided from September 22, 2021, to 
October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 23, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the claim was filed timely. The 
Plan denied your request. The Plan says the provider did supply evidence that claim was attempted to be billed 
once before, but provider failed to re-file claim within timely file, despite being timely notified of rejection of 
initial claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for subsequent nursing facility care was not filed until January 18, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on 
March 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assisted care services provided from December 11, 2019, 
to December 19, 2019. 
 
You asked the Plan to pay for the assisted care services. You say that your coverage includes part time skilled 
nursing and home health aide services so the services rendered should be covered. The Plan denied your 
request. The Plan says the services provided is a non-covered service. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the assisted care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the 
assisted care services provided from December 11, 2019, to December 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on November 03, 
2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the copayment. 
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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for outpatient surgery/hospital or ambulatory surgical center. 
 
You have been asked to pay a $100 copayment for a colonoscopy. This item/service falls within the outpatient 
surgery/hospital or ambulatory surgical center 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 waive the copayment 
for a colonoscopy provided on November 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 June 16, 2022. Therefore, 
we decided that the Plan does not have to pay for dental services provided on June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre Sensor. The Plan denied your request. The Plan says the 
enrollee does not require insulin three or more times daily. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Freestyle Libre Sensor.
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 you are requesting an expedited 
reconsideration stating the enrollee needs to go to an LTACH and not a skilled nursing facility. The Plan 
denied your request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on January 10, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on January 10, 2023.