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

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, 
per 30-minute interval (G0277) and hyperbaric oxygen under pressure, full body chamber, per 30-minute 
interval (99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen treatments. You say that the enrollee has a medical 
history of diabetic and peripheral vascular disease, both of which significantly contribute to the impaired 
wound process. Considering the enrollee's medical history, severity of his non healing wounds, and the well 
documented effectiveness of hyperbaric oxygen therapy in cases similar to the enrollee. The Plan denied your 
request. The Plan says the request is not medically necessary because the records show the enrollee does not 
have diabetic wounds that have failed an adequate course of standard therapy. 
 
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 hyperbaric oxygen treatments. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided there is no documentation that the 
enrollee in this case meets all Medicare criteria for approval of HBOT. Provided records in this case do not 
document failure to respond to standard wound care with no measurable signs of healing for at least 30 
consecutive days as required by the National Coverage Determination (NCD) Hyperbaric Oxygen Therapy 
20.29. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen treatments have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute interval 
(G0277) and hyperbaric oxygen under pressure, full body chamber, per 30-minute interval (99183).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home visits and care management services to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the OON home visits and care management services. You say that the care 
in dispute was needed for the treatment of the enrollee's multiple chronic conditions. You say that the OON 
provider is able to provide you with care in the facility where you reside, as they are contracted with the 
Assisted Living Facility as a preferred provider.  The Plan denied your request. The Plan says the requested 
services are readily available through participating providers and through use of telehealth.  
 
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 
home visits and care management 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 genetic testing provided on December 13, 2022, billed 
with codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651, 
and 87653. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have provided medical records to 
support payment. 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 
December 13, 2022, billed with codes 87500, 87641, 87798, 87491, 87496, 87511, 87529, 87532, 87563, 
87591, 87661, 87481, 87651, and 87653.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Humira pen. 
 
You asked the Plan to pre-approve a Humira pen. You say that the enrollee has been taking Humira since 2010 
with excellent control of psoriasis. You also say that you strongly believe the enrollee needs continued access 
to Humira. 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 a Humira pen.  
 
Benefits for a Humira pen 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on December 
14, 2022, billed with codes 87500, 87641, 87798, 87491, 87496, 87529, 87532, 87563, 87591, 87661, 87481, 
87651 and 87653. 
 You asked the Plan to pay for the UTI panel. You say that this test was medically necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the UTI panel have not been met. Specifically, the records show that this was a single panel which 
was unbundled and reported with multiple codes. Therefore, we decided that the Plan does not have to pay for 
the urinary tract infection (UTI) panel provided on December 14, 2022, billed with codes 87500, 87641, 87798, 
87491, 87496, 87529, 87532, 87563, 87591, 87661, 87481, 87651 and 87653.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 22, 2022, to 
November 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was sent in a timely 
manner. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA. Based on this information, we find that the Medicare rules for payment 
of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from October 22, 2022, to November 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic assay rendered on December 13, 
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 were not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that pharmacogenetics testing is covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a listed diagnosis of 
moderate major depressive disorder, single episode. The test order form documents that Abilify has failed to 
work for the enrollee in this case, and that the provider was considering augmenting therapy with a new 
medication or starting/switching to a new medication. The limited clinical documentation does not clearly show 
that the use of or intent to prescribe a drug that has known drug-gene interactions that require a PGx test to be 
ordered to define the safe use of that drug in that patient. The criteria for coverage are not met and the services 
were 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the GeneSight Psychotropic assay rendered on December 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided December 21, 
2022, to December 23, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services rendered were 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 the enrollee presented to the ED with reported blood cultures with positive staph 
bacteremia from his nursing facility. He was treated in the ED with IV fluids and antibiotics. At the time of 
admission, he was hemodynamically stable. His treatment plan included repeat blood cultures and IV fluids 
with antibiotics. The repeat blood cultures were negative. He remained medically stable and was discharged 
without any complications. The documentation does not support that the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier ED 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 December 21, 2022, to December 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for August 23, 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 procedure code 99213 is 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 99213 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is 
spent on the date of the encounter. 
 
We asked our coder 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 these services. Our reviewer says that procedure code 99213 is not supported. Our reviewer found the submitted records do not support that a medically appropriate history 
and/or examination and low-level decision making were provided. Code 99213 is not supported by the records. 
 
We looked at this coder's review, the file, and Medicare rules. 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 procedure code 99213 billed for August 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional physical therapy visits (97110 x 10). 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee has severe osteoarthritis in 
both knees and need physical therapy to maintain function in your knees. You say that the enrollee can benefit 
from more therapy than surgery at this time. The Plan denied your request. The Plan says 10 additional 
physical therapy visits are not medically necessary.   
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has a chronic condition. The enrollee has an effective 
program the enrollee is able to continue at home. Continued input from a skilled therapist 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten (10) additional physical therapy visits (97110 x 10).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 9, 2023. 
 
You asked the Plan to pay for the lab testing. You say that the claim should be processed. 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 lab testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214), injection services (96372), and 
Ketorolac tromethamine (J1885) provided on October 21, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit, injection services, and Ketorolac tromethamine provided OON. 
You say that you were on disability leave due to back injury. You say that you have been seeing this OON pain 
specialist for about 4 years. You say that when you enrolled in the Plan you were told you could still see this 
OON provider.  The Plan denied your request. The Plan says approval was not given before this service was 
provided.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit (99214), injection services (96372), 
and Ketorolac tromethamine (J1885) provided on October 21, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70486, 90471, and 90715 billed for date of 
service December 23, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes are covered on the fee schedule The 
Plan denied your request. The Plan says the services are not payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 90471 has a payment status indicator of Q1, and CPT code 70486 has a payment status 
indicator of Q3. These codes are not separately payable when billed with code such as 99284, that has a 
payment status indicator of V. We find that CPT code 90715 has a payment status indicator of N. This code is a 
packaged item. Payment is packaged into payment for other services. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 70486, 90471, and 90715 billed for date of service December 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (77387, 77470, 77520, 77522, 
77523, 77525, G6002). 
 
You asked the Plan to pre-approve proton beam therapy. You say that you would like the request reprocessed 
for approval for the additional fractions. The Plan denied your request. The Plan says the treatments described 
by the submitted codes are experimental and unproven. The treatments described by the submitted codes would 
not match the treatments the doctor wants to do. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that proton therapy for prostate cancer affords any advantage over IMRT is very 
controversial. Most reports, including a systemic review, conclude that enrollees treated with proton therapy 
fare comparably and/or better to enrollees treated with photon radiation (i.e., IMRT). There is no clear evidence 
that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive 
radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy. The 
bottom line is that proton therapy for prostate cancer is not experimental, and in fact is an accepted treatment 
approach. While the reviewer does not think that proton therapy is an experimental therapy, any potential 
benefit or detriment of proton therapy over standard IMRT is an investigational question. To date, there is no 
compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to enrollees. While NCCN guideline consider proton therapy a reasonable 
alternative they do not describe it as being necessary in lieu of non-proton-based treatment and are quite 
explicit in that there is no evidence of its superiority. The decision is unfavorable as the reviewer does not 
believe the LCD criteria are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (77387, 77470, 77520, 77522, 77523, 77525, G6002).
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. The Plan denied your request. The Plan says a SNF admission is 
not medically necessary, and the enrollee's needs can be met at a lower level of care.  
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.