Persius/hicric huggingface dataset:
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 need this level of care. The Plan denied your 
request. The Plan says your condition does not meet the criteria for an IRF admission.  
 
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 can be provided in a lower 
level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided at a lower level of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular testing provided on July 13, 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 molecular testing provided on July 
13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultraviolet light therapy system, includes bulbs/lamps, timer 
and eye protection provided on May 18, 2023. 
 
You asked the Plan to pay for ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection.. 
You say that the ultraviolet light therapy system was medically necessary. The Plan denied your request. The 
Plan says the records do not indicate an established diagnosis of psoriasis, or that the enrollee has received any 
treatment or evaluation for skin conditions. 
 
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 ultraviolet light therapy system, includes 
bulbs/lamps, timer and eye protection. Our reviewer says that the requested ultraviolet light therapy system is 
not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee with 
reported psoriasis. However, examination findings only described the enrollee with "moist, no rash" to describe 
the skin examination or "no rashes, erythema, or lesion." There was no report of tried and failed treatments for 
the enrollees skin condition. Psoriasis was not listed in their past medical history. There was no objective 
evidence documented to help verify the diagnosis of psoriasis or any other condition that might benefit from 
ultraviolet light therapy to justify this request. Therefore, the ultraviolet light therapy system will be considered 
not medically necessary at this time.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection. 
have not been met. Therefore, we decided that the Plan does not have to pay for ultraviolet light therapy 
system, includes bulbs/lamps, timer and eye protection provided on May 18, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for insertion or replacement of cranial neurostimulator pulse generator or 
receiver (61885) provided on March 1, 2023. 
 
You asked the Plan to pay for the surgical service. You say that this claim was filed using the AS modifier to 
reflect the Assistant Surgery. You also say that this should be reprocessed and paid. The Plan denied your 
request. The Plan says that the records indicate incision was made on the left anterior chest, so the LT modifier 
should have been appended. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided any rule supporting that an anatomical 
modifier must be used outside of a National Correct Coding Initiative (NCCI) edit situation. The Plan has not 
substantiated their denial reason. Therefore, we decided that the Plan has to pay for insertion or replacement of 
cranial neurostimulator pulse generator or receiver (61885) provided on March 1, 2023.  
 
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 lab panel provided on August 15, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says per Local Coverage 
Article A58761, this type of testing must be billed with a single unit of service of a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on August 15, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve denosumab injection (J0897). 
 You asked the Plan to pre-approve denosumab injection. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the member does not have a history of failure, 
contraindication, or intolerance to the formulary alternatives: zoledronic acid and ibandronate. The Plan also 
says that this is not a continuation of therapy in the past 365 days.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 denosumab injection (J0897). Our 
reviewer says that the member does not meet the criteria for a denosumab injection (J0897). Our physician 
reviewer found the Plan requires a trial of drug zoledronic acid and ibandronate before they will approve the 
requested drug. In this case, the patient has not tried and failed the required drugs. Our physician reviewer also 
found that there is no documentation provided indicating that the plan's required drugs would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of denosumab injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve denosumab injection (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277, 99183, 
C9733, 15860). 
 
You asked the Plan to pre-approve HBO therapy. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has wound on the knee following a fall two weeks ago and is receiving standard wound care. The record 
provided does not establish the presence of an enumerated condition for which coverage is available for the 
requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
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 HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy (G0277, 99183, C9733, 15860).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided by an out-
of-network provider on July 6, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you do not agree with the 
payment made on the claim. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $300 copayment per date of service regardless of the number of trips for in and out-of-network 
emergency and non-emergency ground and air ambulance services. 
 The enrollee has been asked to pay a $277.41 copayment for the ambulance services because the allowed 
amount for these services is less than the $300 copayment. These items/services fall within the ambulance 
services benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services 
provided by an out-of-network provider on July 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Thoracic-lumbar-sacral orthosis (TLSO) (L0457) 
provided on May 22, 2023. 
 
You asked the Plan to pay for the Thoracic-lumbar-sacral orthosis. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no indication this item was discussed, needed, or ordered by the treating physician in the 
clinical documents submitted. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the Thoracic-
lumbar-sacral orthosis (TLSO) (L0457) provided on May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on January 26, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records provided do not 
show that 22 or more drug classes were tested on the date in question. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for the drug testing services provided on January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on May 27, 2022, to
June 14, 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 this
service was medically necessary. The Plan denied your request. The Plan says that the records do not support
the Diagnosis Related Group (DRG) billed.

Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital
services at the DRG originally billed. In this case, you billed the inpatient services provided with diagnosis
code, J96.01, defined as Acute respiratory failure with hypoxia. Our Medical Director states that the enrollee
was admitted to the hospital on May 27, 2022, with suspected perforated bowel. An exploratory laparotomy
was performed; no bowel perforation was found. An EGD was performed on June 1, 2022; 1.5 liters of bile
was removed from the stomach. The enrollee was diagnosed with a deep vein thrombosis in his right lower
extremity and was started on Eliquis. There is insufficient clinical documentation to support a diagnosis of
acute respiratory failure with hypoxia. Discharge was delayed due to needing approval for his HIV
medications. The enrollee was discharged on June 14, 2022. The clinical documentation best supports DRG
357 - other digestive system O.R. procedures with complication or comorbidity. Our Medical Director found
that the enrollee's condition did not meet Medicare criteria for the inpatient hospital services provided from
May 27, 2022, to June 14, 2022, at the DRG originally billed.

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 May 27, 2022, to June 14, 2022, at the Diagnosis Related Group
(DRG) originally billed.
Appeal type: ER
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The 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. You can find this rule in the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).

The rules say that as of January 1, 2013, for most evaluation and management (E&M) visit families, practitioners will select visit level based on the level of medical decision making (MDM) or the amount of time spent by the physician or non-physician practitioner. For some types of visits (such as emergency department visits and critical care), in accordance with their CPT codes, practitioners do not have this choice and will use only MDM or only time to bill. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. You can find this rule in the Centers for Medicare & Medicaid Services (CMS), Internet Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on August 11, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says per Local Coverage 
Article A58761, this type of testing must be billed with a single unit of service of a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on August 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services for date of service April 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's 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 the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services for date 
of service April 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx for Prostate Cancer genetic testing (81551, 
88387) provided on June 28, 2023. 
 
You asked the Plan to pay for genetic testing. You say that the requested service is a medical necessity for you. 
The Plan denied your request. The Plan says the requested service is experimental/investigational. 
 
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 genetic testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that prostate biopsies performed on June 28, 2023, showed benign prostatic glands. Criteria are not met 
in this case as you had a negative biopsy. There was no abnormal histopathology finding. You are not being 
considered for repeat biopsy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for ConfirmMDx for Prostate Cancer genetic testing (81551, 88387) provided on June 28, 2023.