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

 
We decided that the Plan does not have to pay for the laboratory services provided on May 19, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
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 the laboratory services 
provided on May 19, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary due to the 
enrollee's condition and medical needs. The Plan denied your request. The Plan says the enrollee does not meet 
the criteria for a skilled nursing facility level of care admission. 
 
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 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral nerve stimulators. 
 You asked the Plan to pre-approve sacral nerve stimulators. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that sacral nerve stimulation for urinary incontinence 
may be covered under 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 sacral nerve stimulators. Our reviewer 
says that the enrollee does not meet criteria for this procedure. Our physician reviewer found there is no 
documentation that the sacral nerve stimulator meets all Medicare criteria for being medically reasonable and 
necessary and otherwise safe and effective 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 sacral nerve stimulators have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacral nerve stimulators.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87641, 87651, 87498, 87502, and 87634 
billed for date of service March 2, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test will aid in the diagnosis of the enrollee. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 codes 87641, 87651, 87498, 87502, and 87634 were included in the respiratory panel 
provided. The panel testing was not billed with a single code as required. 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 87641, 87651, 87498, 87502, and 87634 billed for date of 
service March 2, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Confirm MDx testing (81551) provided on April 19, 2023. 
 
You asked the Plan to pay for the Confirm MDx testing. You say that this testing is standard of care for the 
management of men at risk for undetected prostate cancer. The Plan denied your request. The Plan says that the 
enrollee was not being considered for a repeat biopsy due to persistent risk factors such as elevated/ rising PSA 
and/or abnormal DRE by repeat testing. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the 
Medicare rules section of this letter 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 the Confirm MDx testing. Our reviewer says 
that this service was medically necessary. Our physician reviewer found that as seen in the second criteria, this 
testing may be ordered when the enrollee is being considered for prostate biopsy or repeat biopsy with PSA 
between 4 and 10 for this age group with or without suspicious DRE findings. Therefore, the enrollee meets all 
of the criteria for coverage. 
 
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 Confirm MDx testing have been met. Therefore, we decided that the Plan 
has to pay for the Confirm MDx testing (81551) provided on April 19, 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: 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 IRF admission is necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for 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 the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies.  There is no indication that the enrollee would 
require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain her functional status.  The enrollee can receive 
further services 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 laboratory test provided on August 25, 2022, billed with 
codes 87481, 87500, 87640, 87652, 87653 and 87798. 
 
You asked the Plan to pay for the laboratory test billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 a laboratory 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 laboratory test 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test 
provided on August 25, 2022, billed with codes 87481, 87500, 87640, 87652, 87653 and 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory services provided on January 
27, 2023. 
 
You asked the Plan to waive the deductible for the lab services. You say that you disagree with the deductible. 
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. Your 
contract with the Plan says that there is a $525 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
You have been asked to pay $9.07 towards your $525 deductible for the lab services. The item or service you 
asked the Plan to waive the deductible for falls within the outpatient diagnostic tests and therapeutic services 
and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $525 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. 
This cost sharing is a contractual obligation that had not been met at the time the lab services was received on 
January 27, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory 
services provided on January 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the enrollee is in pain and cannot 
walk more than 30 feet without sitting down. You also say that the enrollee has a condition that produces pain 
with the nerves. The Plan denied your request. The Plan says the clinical value and effectiveness of bone 
marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed 
literature. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not considered medically reasonable and necessary in this case. 
Our physician reviewer found bone marrow aspirate is considered experimental as additional research is 
needed. Therefore, the reviewer found that the request for bone marrow aspirate is not medically reasonable or 
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service April 26, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the clinical value of the testing benefits the 
enrollee. 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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 

We find that 13 units of CPT code 87798 are not supported in the medical record. Specifically, the records do 
not show that 13 organisms associated with code 87798 were tested in this case. Furthermore, panel testing 
should be billed with a single code and not unbundled as individual components. 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 code 87798 billed for date of service April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (E2103) and 
supplies (A4239). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says no medical records were submitted to determine the medical necessity 
of these items. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the CGM and supplies have been met. 
No medical records were submitted for review. Therefore, we decided that the Plan does not have to pre-
approve the continuous glucose monitor (CGM) (E2103) and supplies (A4239).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the upgraded electronics. 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the requested upgraded electronics are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the upgraded electronics. Our reviewer 
says that the requested upgraded electronics are considered medically reasonable and necessary in this case. 
Our physician reviewer found the complexity of the enrollee's seating and positioning needs necessitates a 
more complex Group 3 power wheelchair base. The expandable controller with harness and electronic 
connection are necessary to operate the Group 3 power wheelchair base and the three power options via a 
joystick. These components are required to operate 3 or more power options on a Group 3 power wheelchair. 
Therefore, the requested upgraded electronics are medically reasonable and necessary in this case. 
 
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 upgraded electronics have been met. Therefore, we decided that the Plan has 
to pre-approve the upgraded electronics.  
 
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 genetic testing provided on September 27, 2022, billed 
with codes 81216, 81298 and 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. 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 
September 27, 2022, billed with codes 81216, 81298 and 81317.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service March 1, 
2023.  
 
You asked the Plan to pay for procedure code 87798. You say that these services were reported appropriately. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 19 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87798 billed for date of service March 1, 2023.
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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 enrollee's medical complexity does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. The enrollee does not require an intensive 
rehabilitation therapy, and it is unclear if they would tolerate. There is not a reasonable expectation that this 
enrollee will be able to benefit from the intensive rehabilitation 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that these services will help the enrollee regain their 
independence. The Plan denied your request. The Plan says the services the enrollee needs can be met at an 
alternative 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 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 pre-approve skilled nursing facility (SNF) care.