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

 We decided that the Plan does not have to pay for inpatient hospital services provided on August 28, 2022 to 
August 31, 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 DRG 
807 was correctly billed. The Plan denied your request. The Plan says coverage criteria has not been met. 
Records support DRG 871 instead. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 807. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that DRG 871 is not supported. Our physician reviewer found  the documentation does not consistently and 
completely support the assigned secondary diagnosis code. The decision to remove the secondary diagnosis 
code and adjust the DRG is supported.  
 
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 August 28, 2022 to August 31, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks (MBBs) (64483, 64484).  
 
You asked the Plan to pre-approve the MBBs. You say that you need these injections. You say that you will be 
having surgery but need the injections for relief in the meantime.  The Plan denied your request. The Plan says 
the requested MBBs are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet certain criteria. 
 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 MBBs. Our reviewer says that the 
requested MBBs are not medically necessary. Our physician reviewer found the provided documentation 
indicates the enrollee has documented radiculopathy. Therefore, the reviewer found that the requested MBBs 
are 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 MBBs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve medial branch blocks (MBBs) (64483, 64484).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 concentrator Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found that there is 
no documentation that SpO2 can be maintained above 91% using an oxygen conserving device and a flow rate 
of 1 to 4 L/min. This is a Medicare requirement. 
 
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 concentrator have not been met.  Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair with custom features. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show a need for this power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the 
documentation provided is conflicting in terms of the most appropriate type of wheelchair base and 
components. That the enrollee is noted to have pressure wound so a group 3 power wheelchair with the 
capacity for power tilt and recline may be more appropriate than a group 2 power wheelchair. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 power wheelchair with custom features.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DCISionRT test (0295U) provided on October 10, 2022. 
 
You asked the Plan to pay for the DCISionRT test (0295U). You say that the DCISionRT test (0295U) 
provided on October 10, 2022, was medically necessary. The Plan denied your request. The Plan says the 
DCISionRT test (0295U) provided on October 10, 2022, was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the DCISionRT test (0295U). Our reviewer says that the DCISionRT test (0295U) provided on October 10, 2022, was not medically necessary. Our 
physician reviewer found gene expression analyses, such as DCISionRT, in ductal carcinoma in situ (DCIS) 
patients are not routine. Use is not supported by the National Correct Coding Initiative (NCCI) Guidelines or 
the medical literature. DCISionRT test is currently the subject of an ongoing clinical trial. The service was 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 the DCISionRT test (0295U) have not been met. Therefore, we decided that the 
Plan does not have to pay for the DCISionRT test (0295U) provided on October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88291, 88368, and 88377 billed for date of 
service December 2, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the services 
cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   

The file shows that codes 88291, 88368, and 88377 were billed with the -59 modifier. The medical records do 
not show that the service were a distinct procedural service. Based on this information, we decided that 
Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 88291, 88368, and 88377 billed for date of service 
December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MX seating system (K0108), power seating system, 
tilt only (E1002), electronic connection between wheelchair controller and two or more power seating system 
motors (E2311), expandable controller (E2377), and a harness (E2313). 
 
You asked the Plan to pre-approve a MX seating system, power seating system, tilt only, electronic connection, 
electronic connection, and a harness. 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 power wheelchair accessories are 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 pre-approve a MX seating system, power seating 
system, tilt only, electronic connection, electronic connection, and a harness. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the power tilt is not required as you have 
the ability to shift and are not at high risk for skin breakdown. No major spasticity is noted. You have adequate 
strength to manage standard power drive controls 
 
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 MX seating system, power seating system, tilt only, electronic connection, 
electronic connection, and a harness have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a MX seating system (K0108), power seating system, tilt only (E1002), electronic connection 
between wheelchair controller and two or more power seating system motors (E2311), expandable controller 
(E2377), and a harness (E2313).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (0005U). 
 
You asked the Plan to pre-approve genetic testing. You say that the provider has submitted medical records to 
support the reconsideration of the denied genetic testing. The Plan denied your request. The Plan says the 
service requested is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the review indicates that the enrollee has a diagnosis of elevated PSA. The enrollee has a 
diagnosis of hematuria and hematospermia and right testicular pain and swelling. His most recent PSA was 
2.57. The review indicates that the enrollee does not meet criteria for approval of the requested testing. The 
requested testing is not medically necessary for the enrollee's condition. 
 
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 pre-approve genetic testing (0005U).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99236 billed for date of service January 2, 2022. 
 
You asked the Plan to pay for code 99236. You say that the medical records support the billing of this code. 
The Plan denied your request. The Plan says code 99236 is not supported by the medical record. The record 
does not document a comprehensive examination. 
 
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 99236 is observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: a comprehensive history, a comprehensive examination, and medical decision making 
of high complexity. 
 
 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 code 99236. Our reviewer says that code 99236 is not 
supported by the medical record. Our reviewer found the provided records in this case document a chief 
complaint, an extended history of present illness, a review of all additional body systems and a complete past, 
family and social history as was allowed by the patient's acute condition. However, the provided records in this 
case do not document a general multi-system examination or a complete examination of a single organ system. 
The provided records do not document examination of eyes, ears, nose, throat, mouth, genitourinary, skin, 
psychiatric, hematologic, lymphatic or immunologic systems as is required for a general multi-system 
examination. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99236 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99236 billed for date of service January 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 19, 2022, billed 
with codes 81162 -90, 81201 -90, 81218 -91, 81292-90, 81295-90, 81298-90, 81307-90, 81317-90, 81321-90, 
81351-90, 81209-90, 81314-90, 81334-90, 81345-90, and 81272-90. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is medically necessary to determine 
risk of cancer. 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 19, 2022, billed with codes 81162 -90, 81201 -90, 81218 -91, 81292-90, 81295-90, 81298-90, 
81307-90, 81317-90, 81321-90, 81351-90, 81209-90, 81314-90, 81334-90, 81345-90, and 81272-90.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that Injectafer is medically necessary. The Plan denied 
your request. The Plan says a trial of  Ferrlecit, Infed, or Venofer is required before alternatives can be 
considered. 
 
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 Injectafer. Our reviewer says that 
Injectafer is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
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 has a history of multiple falls and 
inpatient rehabilitation is medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet all the requirements. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has severe back pain and left lower 
extremity pain. The Plan denied your request. The Plan says the request for an MRI is not medically necessary 
at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee has had a 
normal neuro exam with no red flags. The record does not indicate that a trial of conservative therapy has been 
tried and failed. The elements of the coverage criteria are not satisfied. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRI of the lumbar spine.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) therapy. 
 
You asked the Plan to pre-approve TMS 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 TMS 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 pre-approve TMS therapy. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee did not show 
documentation of electroconvulsive treatment (ECT) however he has undergone transcranial magnetic 
stimulation (TMS) in the past. The enrollee has no clear documentation of a 50 percent improvement of 
depressive symptoms utilizing this mode of therapy. The enrollee does not have an indication for the requested 
TMS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcranial magnetic stimulation (TMS) therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (e.g., hereditary 
hypercoagulability) gene analysis, 20210G>A variant (81240). 
 
You asked the Plan to pre-approve genetic testing. You say that this should be a covered benefit. The Plan 
denied your request. The Plan says the request is not a covered benefit of Medicare or the Plan. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules say that testing for these genes for all risk factors, 
signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are not covered except for 
pregnant enrollees. The records show that you are currently not pregnant, therefore, the test is not covered. 
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 pre-approve F2 (prothrombin, coagulation factor II) (e.g., 
hereditary hypercoagulability) gene analysis, 20210G>A variant (81240).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics testing panel billed for date of service 
November 7, 2022. 
 
You asked the Plan to pay for the billed services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says there is a more appropriate code that should be used. 
 
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 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 the pharmacogenomics testing panel billed for date of service November 7, 
2022.