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

 
We decided that the Plan does not have to pay for the genetic testing provided on January 3, 2023, billed with 
codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240-59, 81241-59, 81291-59, 81306-59, 81328-59, 
81335-59, 81479-GY, 59, 81238-59. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachment and 
reconsider the charge which were previously denied. 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 
January 3, 2023, billed with codes 81225, 81226, 81227-59, 81231-59, 81232-59, 81240-59, 81241-59, 81291-
59, 81306-59, 81328-59, 81335-59, 81479-GY, 59, 81238-59.
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 are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says you 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
chest pain. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
You do 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 you 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the step therapy guidelines were not followed. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that based on the 
medical records provided, there is no indication that the enrollee has tried and failed zoledronic acid. Based on 
the medical records provided and the Medicare-approved major drug compendia there is no indication that the 
plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
Additionally, there is no documentation that the enrollee has a history of an osteoporosis-related fracture. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colorectal cancer screening provided on June 07, 2023. 
 
You asked the Plan to pay for colorectal cancer screening. You say that this service is supported in the records. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for colorectal cancer 
screening provided on June 07, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0315U) provided on June 8, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for biomarker testing to be covered the 
biomarkers must have proven clinical validity/utility. Providers managing oncological conditions must 
demonstrate that the use of biomarkers will be used to assist in the management/treatment of the beneficiary. 
 
We looked at the file and Medicare rules. The DecisionDx-SCC test is non-covered according to the DEX 
Diagnostic Exchange registry. The tests does not have proven clinical validity/utility. 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 genetic testing (0315U) provided on June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end stage renal disease (ESRD) services provided from 
July 3, 2023, to July 13, 2023. 
 
You asked the Plan to pay for the ESRD services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that code(s) and related dollar amount(s) identify 
monetary data that are necessary for the processing of this claim. The codes are two alphanumeric digits and 
each value allows up to nine numeric digits (0000000.00). 
 
We looked at the file and Medicare rules. In this case, value codes and amounts for codes 48, 49, and D5, were 
not reported. Based on this information, we decided that Medicare rules for coverage of the ESRD services 
have not been met. Therefore, we decided that the Plan does not have to pay for the end stage renal disease 
(ESRD) services provided from July 3, 2023, to July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) or receiver, and supply 
allowance provided on July 13, 2023. 
 
You asked the Plan to pay for the CGM or receiver and supply allowance. You say that the services were billed 
correctly and have submitted the medical documentation to support. You also say that you are requesting that 
the claim be reprocessed and paid. The Plan denied your request. The Plan says proof of delivery is required, 
the documentation submitted does not include valid proof of delivery, therefore payment is not supported at 
this time. 
 
The Plan must follow Medicare rules. Medicare rules say that for any items that do not have proof of delivery 
from the supplier, such claimed items shall be denied. 
 
We looked at the file and Medicare rules. The record does not contain a valid description of the item(s) being 
delivered. Based on this information, we decided that Medicare rules for coverage of the CGM or receiver and 
supply allowance have not been met. Therefore, we decided that the Plan does not have to pay for a continuous 
glucose monitor (CGM) or receiver, and supply allowance provided on July 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 6, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on July 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
December 13, 2022, to December 31, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee was treated for post-
surgical edema/inflammation and post-surgical secondary lymphedema by these services. The Plan denied your 
request. The Plan says a PCD coded as E0675 to treat PAD is not eligible for reimbursement. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided December 13, 2022, to December 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95939, 95938, 95937, G0453) provided on 
February 21, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 The Plan must follow Medicare rules. Medicare rules say that only certain diagnosis codes support medical 
necessity for codes 95939, 95938, and 95937. 
 
We looked at the file and Medicare rules. Per LCA A56773, diagnosis code N48 does not support medical 
necessity for codes 95939 and 95938. Per LCA A54095, diagnosis code N48 does not support medical 
necessity for code 95937. Based on this information, we decided that Medicare rules for coverage of codes 
95939, 95938, and 95937, have not been met. 
 
Medicare rules also 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 G0453 is Continuous intraoperative neurophysiology 
monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to 
one patient) each 15 minutes (list in addition to primary procedure). 
 
We find that payment for CPT code G0453 is not supported in the medical record. Specifically, code G0453 
was not billed with a primary procedure. Based on this information, we decided that Medicare rules for 
coverage of code G0453 have not been met. Therefore, we decided that the Plan does not have to pay for the 
services (95939, 95938, 95937, G0453) provided on February 21, 2023.
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 an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says an LTACH admission is not medically necessary, but 
they may review alternate settings if requested such as a skilled nursing facility (SNF), outpatient setting or 
home health care. 
 
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 is on doxycycline and receives daily wound care. Their needs do not 
meet LTACH admission criteria. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 1, 
2023, to August 1, 2023. 
 You asked the Plan to pay for SNF care. You say that a stay at a skilled nursing facility from July 1, 2023, to 
August 1, 2023. was medically necessary. The Plan denied your request. The Plan says a stay at a skilled 
nursing facility from July 1, 2023, to August 1, 2023. was 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 pay for 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 you did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You did not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 pay for skilled nursing facility (SNF) care provided from July 1, 2023, to August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar/sacral RFA. 
 
You asked the Plan to pre-approve the RFA. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the criteria for coverage 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 the RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the documentation indicates that the enrollee had a lumbar RFA six months ago, which 
provided 80% relief of pain, however, the duration of pain relief was not documented. The guidelines state that 
a repeat RFA is indicated if there was a minimum of consistent 50% improvement in pain for at least six 
months or at least 50% consistent improvement in the ability to perform previously painful movements and 
ADLs as compared to baseline measurement using the same scale. Therefore, the criteria for coverage have not 
been 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 the RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve lumbar/sacral RFA.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion (20936, 20930, 27279). 
 
You asked the Plan to pre-approve SI joint fusion. 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 minimally-invasive surgical (MIS) fusion of the 
sacroiliac (SI) joint is considered medically necessary when certain 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 pre-approve SI joint fusion. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no SI joint instability, fracture, 
or lesion. SI joint fusion for degenerative back pain is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusion (20936, 20930, 27279).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan and CT scan. 
 
You asked the Plan to pre-approve a PET scan and a CT scan. You say that the requested imaging is medically 
necessary. The Plan denied your request. The Plan says the requested imaging does not meet the Medicare or 
Plan coverage criteria.  
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET scan and a CT scan. Our 
reviewer says that the requested imaging is not medically necessary. Our physician reviewer found a cardiac 
magnetic resonance imaging (MRI) in 2020 was negative for cardiac sarcoidosis. There is no evidence of a 
malignant process. Guidelines do not support the use of cardiac PET imaging in this role. As a result, at this 
time cardiac PET/CT scanning would not be considered medically reasonable and necessary in the enrollee's 
clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET scan and a CT scan have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a PET scan and CT scan.
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 cannot be safely discharged home. They 
require IRF services in order to get stronger so they can walk on their own. The Plan denied your request. The 
Plan says the request is not medically necessary.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services performed on dates of service 
January 6, 2021, February 11, 2021, March 6, 2021, April 6, 2021, May 13, 2021, June 17, 2021, July 5, 2021, 
July 21, 2021, August 23, 2021, August 30, 2021, and September 2, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that the chiropractic services should be paid as 
billed because they were billed correctly. The Plan denied your request. The Plan says this claim is a duplicate 
of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 10, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the chiropractic services have not been met. 
Therefore, we decided that the Plan does not have to pay for the chiropractic services performed on dates of 
service January 6, 2021, February 11, 2021, March 6, 2021, April 6, 2021, May 13, 2021, June 17, 2021, July 
5, 2021, July 21, 2021, August 23, 2021, August 30, 2021, and September 2, 2021.