Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically cleared and 
ready to be transported to the LTACH. The Plan denied your request. The Plan says that the criteria for 
LTACH admission was not met and the enrollee's needs can be met at a skilled nursing facility (SNF). 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found that the documentation supports that a SNF where the enrollee is currently as provided by the 
Plan has not been able to provide a high enough level of care, and the enrollee has had deterioration of his 
chronic wound that would benefit from a higher level of care in a hospital such as an LTACH, and would be 
anticipated to stay greater than 25 days. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve the LTACH 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 27, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says 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 does not show that the required unique identifier 
was reported. 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 laboratory services rendered on 
February 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial and request 
reconsideration due to medical necessity. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for approval of the requested device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease in the setting of lung cancer treated 
with radiation. The record indicates that the enrollee was prescribed continuous positive airway pressure 
(CPAP). The provided primary source documentation does not contain sufficient detailed information in the 
medical record to justify the treatment selected. The enrollee could be treated with a bi-level positive airway 
pressure (BiPAP) machine with average volume-assured pressure support capability if needed and failure of 
such a device has not been documented. The elements of the coverage criteria are not satisfied. The requested 
service cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 for date of service 
February 28, 2023. 
 
You asked the Plan to pay for the critical care services coded 99291. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services were not billed with an appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that modifier -25 or -24,, must be used to indicate that the critical care was unrelated to the 
specific anatomic injury or general surgical procedure performed. 
 
We find that CPT code 99291 is not payable as billed. Specifically, modifier -25 or -24 must be used to 
indicate that the critical care was unrelated to the specific anatomic injury or general surgical procedure 
performed. This service was not billed with a modifier. Without the appropriate modifier, the claim is not 
payable as billed. Based on this information, we decided that Medicare rules for coverage of the critical care 
services coded 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the 
critical care services coded 99291 for date of service February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vision services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the vision services. You say that the service should be covered. The Plan 
denied your request. The Plan says there are in-network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the vision services to be provided by an out-of-network (OON) provider.
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 January 5, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. 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 January 
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 13, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that these tests are included in the dialysis rate. 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 13, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that the enrollee has had functional and clinical 
status changes thus would be expected to require continued assessment by skilled nursing and skilled therapy. 
Clinical documentation shows that prior level of function was independent with mobility and self-care tasks, 
currently requiring maximum assist with mobility and self-care tasks; physical therapy and physical medicine 
and rehabilitation consultation recommending daily skilled therapies in SNF setting. Clinical documentation 
shows that the enrollee has had multiple medical complications and would be expected to require frequent labs, 
skilled nursing assessments thus the enrollee would be expected to require daily skilled services. From a 
practical standpoint, clinical documentation does show that the enrollee requires 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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the flow cytometry services coded 88189 for date of service 
October 19, 2022. 
 
You asked the Plan to pay for the flow cytometry services coded 88189. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 88189 must be billed with certain diagnosis 
codes to support medical necessity and coverage. 
 
We looked at the file and Medicare rules. Review of the file shows that code 88189 was billed with diagnosis 
code R91.8. Diagnosis code R91.8 is not listed as a covered diagnosis code for code 88189. Without a covered 
diagnosis code billed on the claim, code 88189 is not payable as billed. Based on this information, we decided 
that Medicare rules for coverage of the flow cytometry services coded 88189 have not been met. Therefore, we decided that the Plan does not have to pay for the flow cytometry services coded 88189 for date 
of service October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on March 16, 2023. 
 
You asked the Plan to pay for the testing. 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 does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the provided records do not provide adequate detailed information to meet Medicare criteria for coverage of a 
ventilator as opposed to a bilevel positive airway pressure (BiPAP) device with average volume assured 
pressure support (AVAPS) and a back-up rate. The provided records do not document trial and failure of a 
BiPAP device with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued use of a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service February 10, 
2023. 
 You asked the Plan to pay for procedure code 87640. The Plan denied your request. The Plan says payment for 
code 87640 is bundled into payment for code 87641. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87640 
is a column II code to column I code 87641. Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 87640 billed for date of service February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hereditary/genetic colorectal cancer panel (81435, 
81436). 
 
You asked the Plan to pre-approve a hereditary/genetic colorectal cancer panel. You say that this testing is 
medically necessary. The Plan denied your request. The Plan says this test 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 a hereditary/genetic colorectal cancer 
panel. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee does not meet National Comprehensive 
Cancer Network (NCCN) or Amsterdam criteria for genetic testing for colorectal cancer. No family history is 
provided, and the enrollee has no personal history of colorectal cancer or other high-risk criteria for testing. The service is not reasonable or 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 a hereditary/genetic colorectal cancer panel have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a hereditary/genetic colorectal cancer panel (81435, 81436).
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 enrollee meets criteria for and will benefit from 
acute inpatient rehabilitation. The Plan denied your request. The Plan says the IRF services you are requesting 
do not meet the requirements for approval. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an ESI. 
 
You asked the Plan to pre-approve an ESI. You say that you are appealing the denial. The Plan denied your 
request. The Plan says that the enrollee does not meet LCD criteria.  
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injections may be covered 
under certain circumstances. 
 
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 epidural steroid injection (ESI). Our 
reviewer says that the enrollee does not meet the coverage criteria for this procedure. Our physician reviewer 
found that the enrollee's back pain is axial, without radiculopathy. Per the coverage criteria, epidural steroid 
injections require pain to be radicular and history, physical examination, and concordant radiological image-
based diagnostic testing must support pain due to 1 or more of the following: disc herniation, osteophyte or 
osteophyte complexes, or severe degenerative disc disease that produces foraminal or central spinal stenosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection (ESI) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an ESI.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 27, 
2023. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP Panel (81455) provided 
January 8, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that you respectfully request support of this request 
for coverage of the Tempus Liquid Biopsy CGP Panel for the enrollee. The Plan denied your request. The Plan 
says the requested test is not reasonable and necessary because this test not FDA approved. 
 
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. Tempus xF has not had FDA approval or clearance as a companion in 
vitro diagnostic or an FDA-approved or -cleared indication for use in this enrollees cancer. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP Panel (81455) provided 
January 8, 2023.